World Bank Document

WORLD BANK WORKING PAPER NO. 212 Public Disclosure Authorized Private Health Sector Assessment in Mali Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized

THE WORLD BANK

WORLD BANK WORKING PAPER NO. 212

Private Health Sector Assessment in Mali The Post-Bamako Initiative Reality

Mathieu Lamiaux François Rouzaud Wendy Woods

Investment Climate Advisory Services of the World Bank Group Copyright © 2011 The International Bank for Reconstruction and Development/The World Bank 1818 H Street, NW Washington, DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org

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World Bank Working Papers are published to communicate the results of the Bank’s work to the development community with the least possible delay. The manuscript of this paper therefore has not been prepared in accordance with the procedures appropriate to formally-edited texts. Some sources cited in this paper may be informal documents that are not readily available. This volume is a product of the sta of the International Bank for Reconstruction and Development/The World Bank. The ndings, interpre- tations, and conclusions expressed in this volume do not necessarily re ect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judg- ment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries.

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ISBN: 978-0-8213-8535-7 eISBN: 978-0-8213-8795-5 ISSN: 1726-5878 DOI: 10.1596/978-0-8213-8535-7

Library of Congress Cataloging-in-Publication Data has been requested. Investment Climate in Health Series

his subseries of the World Bank Working Papers is produced by the Investment Cli- Tmate Department of the World Bank Group. It is a vehicle for publishing new material on the group’s work in the health sector, for disseminating high-quality analytical work, and for consolidating previous informal publications after peer review and standard quality control. The subseries focuses on publications that expand knowledge of government policies and the operating environment and suggest ways of be er engaging the private health sector in treating illnesses among the poor and other vulnerable populations. Best-practice examples of both global and regional relevance are presented through thematic reviews, analytical work, and case studies. The editor-in-chief of the series is Alexander S. Preker. Other members of the edi- torial commi ee are Peter Berman, Maria-Luisa Escobar, Sco Featherston, Charles C. Gri n, April L. Harding, Gerard M. La Forgia, Maureen Lewis, Benjamin Loevinsohn, Ok Pannenborg, Khama O. Rogo, and Marie-Odile Waty. For further information contact:

Therese Fergo Email: [email protected] Rel.: +1 (202) 458-5599

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Contents

Foreword ...... ix Preface ...... xi Acknowledgments ...... xix Acronyms and Abbreviations ...... xxi 1. Introduction and Background Elements ...... 1 The “Health in Africa” Initiative ...... 1 The Malian Context ...... 1 2. Private Health Care under the Malian System ...... 4 History ...... 4 Health Policy in Mali ...... 5 Health Care Delivery ...... 6 Education of Health Care Professionals ...... 11 Pharmaceuticals and Medical Products Distribution ...... 13 Health Insurance...... 16 Clinical Pathway ...... 17 Synthesis: Sizing the Health Care Sector ...... 19 3. Governance, Regulation, and the Business Environment ...... 21 Associating the Private Sector in Governance of the Health System ...... 21 Private Sector Regulation: Strategic Documents and Regulatory Framework ...... 23 Business Environment ...... 24 4. Analysis of the Health System ...... 26 Private Medicine ...... 26 Education ...... 29 Private Community Sector ...... 31 Health Insurance...... 35 Pharmaceuticals ...... 37 Clinical Pathway ...... 39 Governance ...... 40 5. Improving the Private Sector Contribution to Public Health Objectives ...... 41 About Opportunities for Improvement ...... 41 Strengthening the Public-Private Partnership and Dialogue ...... 41 Creation or Revision of Regulatory Texts ...... 45 Reinforcement of Law Enforcement Mechanisms ...... 47 Strengthening the Education Policy ...... 48 Fight against the Illegal Pharmaceuticals Market ...... 50

v vi Contents

Implementation of Quality and Locational Incentives ...... 50 Bolster Rural Community Health by Consolidating ASACO and ...... 52 CSCOM Strengths Voluntary Expansion of Private Mutual Insurance ...... 55 Clinical Pathway ...... 56 6. Operational Proposal for Governance ...... 57 Public-Private Dialogue and Consultation Commi ee ...... 57 Public-Private Partnerships Entity ...... 59 Entrust Questions Related to the Private Sector to a Technical Adviser ...... 59 7. Joint Public-Private Action Plan ...... 60 Perspectives for Further Investigation...... 61 Notes ...... 66 Appendixes ...... 67 A. Methodology and Main Findings ...... 69 B. Project Approach ...... 81 C. Terms of Reference of the Steering Commi ee ...... 83 D. Malian Household Survey Questionnaire on Health Behavior ...... 85 E. Sampling Method for the Malian Household Survey of Health Behavior ...... 95 F. Institutions and Individuals Associated with the Work on ...... 97 Stakeholder Engagement Bibliography ...... 99 Recently Published ...... 101 Forthcoming Publications ...... 101

Boxes 2.1. Main Indicators of the Malian Health Policy ...... 5 2.2. Some Typical Fees ...... 9 2.3. Documents Needed for Authorization to Teach ...... 12 2.4. The Zoning Rules Governing Pharmacy Opening ...... 14 3.1. The Policy-Making Bodies for the PRODESS ...... 22 5.1. Wholesaler License Requirements ...... 45

Figures 1.1. The Malian Population, by Age Group ...... 2 1.2. How Mali Compares with the Average of All Sub-Saharan ...... 3 African Countries 1.3. The Organization of the Health System ...... 4 2.1. Evolution of CSCOM Accessibility ...... 7 2.2. Population within 15 km of a CSCOM ...... 7 2.3. Distribution of Physicians, by Main Practice Location, 2008 ...... 8 2.4. Contact Rate, by Provider Type ...... 9 Contents vii

2.5. FMPOS-Educated Physicians ...... 12 2.6. Overview of Drug Distribution ...... 13 2.7. Waiting List for Licenses to Open a Pharmacy, by Region ...... 14 2.8. Pharmaceutical Sales by Private and Public Wholesalers ...... 15 2.9. Scheduled Funding for the Social Protection Extension Plan, 2005–09...... 16 2.10. Growth of Private Mutual Insurance Entities and Bene ciaries ...... 17 2.11. Advice-Seeking versus Self-medication: Patient Behavior in Response to ...... 18 Health Problem 2.12. Breakdown of Health Providers, by Consultation ...... 18 2.13. Choice of Providers Depends on Household Income...... 19 2.14. Growth of Health Expenditures in Mali ...... 20 3.1. Average Lead Time to Obtain a Permit and a License ...... 25 4.1. Systemic Representation of the Health System ...... 26 4.2. Market Absorption Capacity for New Private Practices and Hospitals, 2009 ...... 27 4.3. Market Absorption Capacity versus Young Physicians’ Hopes for Opening ...... 30 Private Practices and Hospitals 4.4. Financial Balance of an Average CSCOM ...... 31 4.5. CSCOM Typology, by Catchment Area and Contact Rate ...... 33 4.6. Health Insurance Coverage Rate, 2015 ...... 35 4.7. Expansion of Health Insurance Coverage in a Compulsory Subscription ...... 36 Scenario 4.8. Impact of the Contact Rate on CSCOM Turnover ...... 37 4.9. Compulsory Model with Constant Premium versus a Compulsory Model ...... 38 with Rising Premium 4.10. Backlog in New Pharmacy Licenses until 2014 ...... 38 5.1. Estimated Annual Funding Needs to Start New Practices and Private ...... 51 Hospitals 5.2. Estimated Annual Funding Needed to Start New Pharmacies ...... 52 5.3. Ideal Growth Pro le for Di erent CSCOM Types ...... 54 5.4. Estimated Annual Funding to Establish Rural Physicians ...... 54 5.5. Private Mutual Insurance to Depend on Task Pooling with the UTM ...... 55 5.6. Breakdown of Mutual Insurance Cost Items ...... 56 6.1. Proposed Organization of the Public-Private Dialogue and Consultation ...... 58 Commi ee B.1. The Project Approach ...... 81

Tables 1.1. Mali: Economic Indicators ...... 2 1.2. How Mali Ranks, Selected Indicators ...... 3 2.1. Private HC Provider Geographic Distribution ...... 10 2.2. Average Cost and Cost Structure of Health Care Services, by Provider...... 11 2.3. Grades Given by Patients to Provider Performance on Evaluation Criteria ...... 11 2.4. Breakdown of Health Expenses in Mali, 2008 ...... 20 5.1. Adjustment Needs of Mutual Insurance over Their Lifecycle ...... 57 7.1. Joint Public-Private Action Plan ...... 62 viii Contents

A.1 Contact Rate per Health Care Provider ...... 72 A.2 Estimated Distribution of Private Providers, by Region ...... 72 A.3. Average Expenditures in Private Practices and Hospitals ...... 73 A.4. Estimated Number of Additional Private Practices and Hospitals that Can ...... 74 Reach Breakeven A.5. Projected Growth in the Number of Private and Public Physicians ...... 74 A.6. Estimated Number of New Private Practices and Hospitals Enabled ...... 75 by Se lement of Young Physicians A.7. Funding Needs of New Private Practices/Hospitals Enabled by Se lement ...... 75 of Young Physicians A.8. Funding Needs Associated with Support of Rural Physicians ...... 76 A.9. Hypotheses for Modeling Mutual Insurance Deployment under Compulsory ...... 77 Subscription A.10. Results of Compulsory Subscription Model ...... 78 A.11. Hypotheses for Modeling a Typical CSCOM ...... 79 A.12. Results of Typical CSCOM Model ...... 79 A.13. Breakdown of Pharmacy Turnover, 2008 ...... 80 A.14. Distribution of Pharmacies and Waiting Lists, by Region ...... 80 Foreword

ali was one of the rst countries to open its health system to private community- Mbased and NGO-based health care. In 1989, the Minister of Health, in the context of the Bamako Initiative, authorized the creation of the country’s rst health center managed entirely by the community, through a Community Health Association (ASACO). Mali is proud of the 990 community centers (CSCOMs) that have been opened since that time in nearly every part of the country under an aggressive policy to expand geographic coverage of primary health care. These private, not-for-pro t, community-based health associations constitute a unique feature of the Malian health system and form the foundation of the health pyramid. They also occasioned the development of the rst public- private partnerships in the area of health, with government supporting their foundation and, later, their operation. Mali has also been active in the development of private community-based mutual health insurance and now has 128 approved schemes. Finally, Mali counts many nongovernmental and faith-based organizations that are active in the area of health as well as numerous traditional practitioners that belong to a federation. Parallel to this strong community- and NGO-based health sector, the private commercial sector has also grown, under the dual impulsion of the health sector liberalization of 1985–86 and the strong increase in demand for health services, especially in cities. The private, for-pro t, health care sector today encompasses about 250 medical and nursing practices and 80 hospitals—most of them, unfortunately, located in cities. The pharmaceutical sector is almost entirely in private hands, accounting for 80 percent of turnover. And last, the number of private schools has mushroomed since the liberalization of health education and training. With this progress, the Malian Ministry of Health is eager to develop policies that will allow the private sector’s resources and know-how to be fully tapped. The ministry is aware that national health goals cannot be reached without long-term engagement of all the health sector actors, whether they are not-for-pro t, for-pro t or civil society groups. Therefore, the Ministry of Health requested support from the International Fi- nance Corporation and the World Bank to carry out a comprehensive assessment of the role of the private health sector and identify key areas for reform and partnership. The assessment analyzed the current contribution of the private sector in every area of the health system: policy and regulation; delivery of care, medicines, and other health products and services; education and training of health professionals; and health nancing. This comprehensive assessment, which had never been previously done in Mali, enabled us to collectively identify strategies for improving the private sector’s contribution to health goals and developing public-private partnerships. By enlisting broad and active participation, this assessment has helped break the ice between the public and private sectors, put the problems on the table, and spur the search for solutions that can be achieved in the short and medium terms. The study’s ndings are very timely as they will feed the preparation of the new Ten-Year Health and Social Development Plan (2012–21), which has just begun.

ix x Foreword

This “Assessment of the Private Health Sector in Mali” was successfully conducted thanks to the political will of the government of Mali and strong leadership from the Ministry of Health. This continued impetus will be decisive in implementing public private partnerships in support of public health activities. As Chairman of the study Steering Commi ee, I had the responsibility and pleasure of seeing this work through. I thank all participants for their contributions to its success.

Salif Samake Chairman, Steering Commi ee Preface

his country assessment of the private health sector in Mali is part of a series of stud- Ties designed to deepen understanding of ways to enhance the health policy framework, business environment, and investment climate in which the private health sector operates in African countries. The Malian health system has evolved dramatically since the middle of the 1980s. Two signi cant reforms included the 1985 liberalization in private practice and implementation of the Bamako initiative. Since then the private sector has grown to the point where today it delivers around 50 percent of all health care goods and services in the country, with a focus on the following areas: Treatment. Eighty percent of curative consultations take place in the private community and in commercial areas, and 50 percent of physicians work mainly in the private sector. Pharmacy. Private players account for 80 percent of turnover (at selling price), and 50 percent of public entities’ needs are covered by private wholesalers. Education. About 50 percent of individuals who pass the Superior Health Tech- nician (TSS) examinations are educated in private schools, as are 90 percent of those who pass the Health Technician (TS) examinations. Health insurance. All mutual insurance programs (mutuelles) are privately organized. Despite this valuable contribution by the private health sector in Mali, much more research is needed to fully understand its size, con guration, quality of care provided, a ordability and contribution to overall health sector objectives and outcomes. International Finance Corporation (IFC) and the World Bank conducted the review of the private health sector presented in this report for the government of Mali with nancial support from the Bill & Melinda Gates Foundation and in close consultation with the Ministry of Health, other stakeholders, and the development partners. The study was carried out by The Boston Consulting Group in collaboration with RESADE, the Malian Ministry of Health , discussion partners from the private sector, and other stakeholders in the Malian health system . It included two parallel work streams: An analytical work stream that would identify the private sector’s role in the health care system and examine the main stakes of each of its segments (treatment, education, drugs, insurance) and components (commercial, community, associations, religions, traditional culture) and A stakeholders’ engagement work stream that would validate and enrich the ndings, discuss improvement axes, and sketch out the operational modalities.

Methodology De nition of Private Health Sector Private health sector, as used in this study, is de ned broadly to encompass all the commercial and not-for-pro t components of health care, including community services.

xi xii Preface

The private nature of community health centers has been well established since the beginning. Community health associations (ASACOs) were created by civil society. To- day, community health care is still managed by the bene ciaries themselves through those associations. Politically, the choice made at that time to entrust primary health care to the communities has not been challenged. These organizations have been expanded as a result of a deliberate policy choice. Juridically, ASACOs/CSCOMs are constituted under private law, and their accounting practices distinguish them from the public institutions under the Ministry of Health. They are supported and advised by public authorities and supervised by regulatory bodies, all of which delineates, but does not suppress, their managerial autonomy. Financially, their public subsidies do not exempt them from having to balance their accounts.

Economic and Financial Modeling A large part of the analysis in this report relies on the reprocessing and the mining of existing databases, the nancial and macroeconomic models based on those data, and elements reconstructed through triangulation. Those calculations proved indispensable for assessing the main demographic trends in the private sector, for estimating the growth of CSCOMs and private mutual insurance (mutuelles), and identifying how to reinforce them. This method provides results in terms of both public health and the nancial im- plications of the recommendations. The study modeling relies on the construction of a typical microstructure (typical CSCOM and average rural mutuelle) and on a switch to the macro scale to measure the e ciency of supporting nationwide policies.

Main Findings

After systemic analysis of the sector, the following ndings were drawn up and shared with all public and private participants in working sessions and three seminars. These ndings address each component of the health care system: private medicine, education of health care professionals, community health care, private mutual insurance, pharmaceuticals, and governance.

Governance Concerning governance, the main ndings were: The private sector, whose legitimacy is still to be consolidated, is not yet suf- ciently included in the de nition of health care policies. (It is not represented within the national bodies that monitor the Health and Social Development Program (PRODESS, the main strategic health care policy document). The same goes for the role of the private sector in the de nition of the regulatory environment, due to the absence of su ciently speci c and inclusive forums for dialogue and consultation.

Private Medicine Concerning private medicine, the main ndings were: Uneven distribution of private health care throughout Mali, with a heavy concentration in Bamako, limits market absorption capacity and fosters the development of an informal sector with lower prices and lower-quality services. Preface xiii

Poor communication with the public sector limits private sector inclusion in the public service missions of education and vaccination and hampers the exploitation of complementarity between private and public health care structures. Certain rules for classifying health care establishments, perceived by some ob- servers as too rigid, deserve some thought. Young medical professionals believe the start-up phase of their practices is hampered by a lack of support. Banks are reluctant to nance their initial funding requirements. Their training does not address needs related to the realities of private practice or practice in rural areas. More generally, health care professionals su er from an ine cient private sector. Despite improvements in the business environment, Mali ranks 156th out of 183 in Doing Business 2010, a six-place gain from the year before. Limited access to bank loans and tax requirements are the most penalizing factors in the business climate in Mali, compared with other Sub-Saharan African countries.

Rural and Community Health Concerning rural and community health, the main ndings were: Despite historical success in terms of coverage, with 87 percent of the population located within a 15-km radius of a center in 2009, the average CSCOM su ers from low personnel productivity, insu cient tra c and demand, and ASACO’s limited management capabilities, which run up costs. Thus, the average CSCOM depends on subsidies to meet expenses. The current policy of strengthening CSCOM services responds inadequately to the shortage of demand. Big public health care decisions (free health care, especially) should take into account more fully the principle of cost recovery on which community health relies. CSCOMs are placed in speci c intrinsic situations that should be taken into account when decreasing the support provided to them. Finally, the success of strategies to develop medical care requires support for physicians who se le in CSCOM.

Pharmaceuticals Concerning pharmaceuticals, the main ndings were: The irregular sca ering of pharmacies throughout the country limits market absorption capacity. Improvements are needed for the start-up phase of pharmacies and also training of pharmacists. Funding needs are partly covered by pharmacy partners (wholesalers). The skills and knowledge needed to start up a pharmacy are poorly taught.

Education of Health Care Professionals Concerning education of health care professionals, the main ndings were: The lack of regulation over the number of students enrolled in initial training and by the poor quality of some of the teaching weaken this sector. The growth of the private sector is further held back by insu cient educational preparation for practice in the private sector and in rural areas. xiv Preface

Mutual Insurance The main ndings about mutual insurance were: At the current pace of expansion, by 2015 only about 5 percent of the population would be covered by private mutual insurance. Thus, a scale-up is necessary. A scale-up could begin with a phase of preliminary experimentation in one or two pilot regions. One option for changing the scale would be to create 100 mutual insurance schemes to meet the needs of the rural population at an affordable cost (CFA F 300 per month). The impact of such a deployment of mutual insurance would be signi cant for the health care system (increase in the contact rate and activity volume of the CSCOMs) and would allow an increase in demand for health care by alleviating the nancial constraint on households.

Main Recommendations

The following avenues for improvement, resulting from the analyses done for this report and dialogue with stakeholders, were shared at the three seminars mentioned above in the discussion of methodology. From a systemic viewpoint, the recommendations concerning rural and community health and development of mutual insurance appear the most likely to have a major impact on Malians’ state of health and the a ainment of the Millennium Development Goals (MDGs). Mutual insurance development and rural health issues are closely connected, mainly because both target the same, extremely fragile rural population that bene ts the least from the health care system. Such ambitious recommendations probably cannot be implemented without sustained technical and nancial support.

Partnership and Dialogue between the Public and Private Sectors To encourage dialogue between the public and private sectors, the following recommendations were made: A public-private commi ee for dialogue and consultation should be created as soon as possible, organized along the lines of the future dialogue commi ee. Its role could be to render opinions on regulatory proposals that a ect the private sector and to help enrich the body of law relative to public health care. The private commercial sector should be be er integrated in the PRODESS A body should be created to represent the whole private health sector. The above-mentioned precursor to the permanent dialogue and consultation commi ee will give the private sector an additional incentive to appoint interim representatives and rationalize its current organization. A national policy should be designed to reinforce public-private partnerships (PPPs). This policy will present a consistent framework for actions to be er connect the public and private components of the health care system. A close public-private relationship is necessary to build such a policy. Measures should be taken to support the development of public-private partnerships. (A longer-term strengthening of public entities’ capabilities to steer complex contracts appears to be a prerequisite for scaling up PPPs). Speci cally, the Health Equipment and Regulation Division (DESR) should be reinforced, Preface xv

and a section devoted to PPP should be created. Model agreements should also be drafted for sharing equipment and specialties in a given territory and for joint training, laboratory diagnostic, and vaccination activities.

Creation and Revision of Regulatory Texts For the creation and revision of regulatory texts, the following recommendations were made: The requirements should be tightened for authorization to open private schools, to ensure that the school has the requisite supervisory and educational capabilities. The requirements for licensing wholesalers should be tightened. Criteria should be introduced to check the validity of the license applicant’s wholesaling activities. The requirements should be tightened for awarding diplomas in the health care sector at the risk of creating several health professional markets, because health care is not a state monopoly. Thought should be given to the zoning rules for physicians, because 70 percent of Mali’s physicians are located in Bamako with only 30 percent covering the rest of the country Thought should also be given to strengthening the mechanisms for accreditation and veri cation. In the context of compulsory health insurance (AMO), quality accreditation should be introduced. The Ministries of Health and Edu- cation should work especially closely in these areas.

Law Enforcement Mechanisms

The self-regulation capabilities of the professional councils (ordres) should be strengthened. This includes reinforcement of sta within professional associations. Thought should also be given to ways professional associations might exercise their disciplinary roles. An ombudsman should be created for the private sector (discussed below). His or her task would be to broker amicable agreements between the administration and complainants. The ombudsman would also propose improvements in laws and procedures.

Education Policy The educational network’s tools for improving regulations and quality should be strengthened by Negotiating legally restrictive agreements se ing maximum education capacity for each private higher-education organization in the health eld Changing the current qualifying examinations into competitive exams for the jobs of health technician (TS) and senior health technician (TSS) Establishing a state monopoly for awarding health care diplomas Giving some thought to siting of educational establishments. Training capacity for physicians and pharmacists should be expanded by Working with the private sector (e.g., internships in medicalized CSCOMS and private hospitals, dissertation advising by private physicians xvi Preface

Encouraging opening of decentralized, regional branches of the school of medicine, pharmacy, and Dentistry (FMPOS). Educational standards should be raised to prepare health workers for practice under 21st-century conditions. Speci cally, The education modules preparing health care professionals for practice in the private sector and in rural areas should be reinforced. The councils should organize opportunities for the continuous training of members who enter the private sector, o ering them management training that is appropriate for private practice, especially during their rst year. Within the CSCOMs or other organizations, an e ort should be made to train physicians who will set up their practice in rural areas in order to promote programs to improve medical care those regions.

Geographical Distribution and Quality Improvements of the Private Commercial Sector To improve the geographical distribution and quality of private commercial health care, the following recommendations were made: A speci c o ce should be created within the professional associations to publicize available incentives, for example, under the Investment Code and the tax regime. For-pro t and not-for-pro t health care providers, pharmacies, and schools should be given be er access to funding during start-up. Partial guarantee of bank funding could be extended up to 50 percent of an asset portfolio of CFA F 1 billion (that is, about 50 percent of funding needs to se le practices, private hospitals, and pharmacies from 2010 to 2012). Other nancial engineering strategies (participation, etc.) could also be devised. Fiscal incentives should be targeted toward se lement of less densely population regions under or as a complement to the Investment Code. Additional advantages would be o ered health care professionals for investments in these areas: prolongation of the scal exemption. A solution should be designed for pharmacists who receive no incentives under the Investment Code. Consideration should be given to a pricing agreement among private practitioners that participate in the compulsory health insurance (AMO). Begin to think about the zoning rules for private physicians (discussed below).

Reinforcement of Rural and Community Health Care Among action to strengthen rural and community health care, the following recommendations were made: Strengthen ASACO and CSCOM management capabilities. CSCOM partners should be sensitized to the necessity of avoiding weakening ASACO management, making sure the support provided to them responds to their actual needs. Support continuous training programs for ASACO members. Provide external support to ASACOs that feel the need to reinforce their management capacity. These managers would be selected from among the applicants responding to an invitation from a group of ASACOs. They would take charge of the delegated management of CSCOM on their behalf under the direction of the center head. They would have an advisory role in strategic decisions. Their compensation could be partly indexed on their result. Preface xvii

Redirect current subsidies toward the CSCOMs’ actual needs in their particular situations (discussed below). Personnel not actually occupied in CSCOM’s activities should be gradually withdrawn. State support and advice should be redirected toward the audit of their nancial viability. The support provided to CSCOMs should be tailored to their speci c situations. Further develop rural medical care. Support programs for rural health care networks should be intensi ed after assessment of their impact and sustainability. Accelerate the se lement of physicians in CSCOMs. To this end, establish a tripartite agreement between the state, the National Federation of Community Health Associations (FENASCOM) and any partner interested in participating in a program to support the development of rural medical care.

Aggressive Expansion of Private Mutual Insurance To expand private mutual insurance, the following recommendations were made: Give initial support for the scale-up of the Technical Union of Malian Mutual Insurance System (UTM) to expand coverage in the context of initiatives for overall expansion of health care insurance. One of the options involves initiat- ing an ambitious two-year trial in one or two regions. Lessons drawn at the end of this trial would allow the means of expansion to be adapted to t the Malian context. This would be done through support to the UTM and social mobilization e orts. The small sta of UTM and the social development services could handle the job with the help of an outside contractor, selected by the UTM and the state through an invitation to tender. Review, on the basis of existing private mutual insurance, the best means of supporting the new insurers after start-up, including improved methods for subsidizing participation by the poor in such programs

Conclusions

The government of Mali has an opportunity to take advantage the large and dynamic private health sector in contributing to its national health care objectives and outcomes. The study describes the various instruments of stewardship towards the private sector that could be used such as information, regulations, nancing and direct provision of public services in areas of signi cant market failure.

Alexander S. Preker Series Editor Head of Health Industry and Investment Policy Analysis Investment Climate Advisory Services The World Bank Group

Acknowledgments

e thank all the stakeholders in the Malian health system who helped us collect Wthe necessary data, shared their knowledge with us, and answered our questions. S. Samaké and Issa Berthe (Planning and Statistics Unit of the Ministries of Health, Social Development, and Family Promotion), B. Mountaga (Technical Advisor to the Health Minister), as well as M. Ya ara (National Directorate of Health), were particularly valuable in helping us navigate our way through the Ministry of Health. We also thank the Bamako representatives of the World Bank for their support, especially M. Magassouba and F. Sidibé. We are especially grateful for the contribution made by Ous- mane Diade Haidara, World Bank health task team leader for Mali, and Marie-Odile Waty, IFC Health Specialist. The other members of the steering commi ee and of the Malian Ministry of Health also provided full assistance and support during this process, in particular N. Coulibaly, president of the National Pharmacists Council, and Fodé Coulibaly (Inspection of Health). Discussion partners from the private sector also played a crucial role. They include O. Oua ara (Care), Nimaga (Association of Rural Physicians), Sy (Santé Sud), L. Fofa- na and A. Traore (Association of Physicians in Private Practice in Mali), Fidi Doumbia (FENASCOM), Cheikna Toure (UTM), Yacouba Koné (Aga Khan Foundation), B. Cissé (Mérieux Center), M. Diallo (Private Sector Coalition), and Issa Traore (ASACO Banconi). Invaluable in the completion of this project were the participants in the three seminars, people met during trips to Bamako and in the regions, the technical and nancial partners interviewed, and the Malian authorities. The RESADE research o ce played a signi cant role in our understanding of the Malian perspective on the health care system. We thank Mathieu Jamot and Sébastien Hua from the Boston Consulting Group (BCG) who largely contributed to the data collection, analysis and writing of this report. Finally, we thank the teams from International Finance Corporation and the World Bank Group (especially Alexander S. Preker, Khama Rogo, Marie-Odile Waty, Connor Spreng, Bousso Drame, and Tonia Marek) for having initiated, nurtured, and supported our work throughout the project.

xix

Acronyms and Abbreviations

AMC Association des Médecins de Campagne—Association of Rural Physicians AMLM Association des Médecins Libéraux du Mali—Association of Physicians in Private Practice in Mali AMO Assurance Maladie Obligatoire—Compulsory health insurance AMV Assurance Maladie Volontaire—Voluntary health insurance ANPE Agence Nationale pour l’Emploi—National Agency for Employment APBEF Association Professionnelle des Banques et des Etablissements Financiers—Professional Association of Banks and Financial Institutions API Agence de Promotion des Investissements—Agency for Investment Promotion ASACO Association de Santé Communautaire—Community Health Association CCIM Chambre de Commerce et d’Industrie du Mali—Chamber of Commerce and Industry of Mali CEDEAO Communauté Economique des Etats de l’Ouest Africain—Economic Community of West African States (ECOWAS) CNIECS Centre National d’Information d’Education et de Communication pour la Santé—National Center of Health Information, Education, and Communication CNOM Conseil National de l’Ordre des Médecins—National Physicians Council CNOP Conseil National de l’Ordre des Pharmaciens—National Pharmacists Council CNOSF Conseil National de l’Ordre des Sages-Femmes—National Midwives Council CPS Cellule Plani cation et Statistiques au sein du Ministère de la Santé— Planning and Statistics Unit (MOH) CSCOM Centre de Santé COMmunautaire—Community health center CSCRP Cadre Stratégique pour la Croissance et la Réduction de la Pauvreté— Strategic Framework for Growth and Poverty Reduction CSREF Centre de Santé de REFérence—Referral Health Center (2nd level) DAF Direction des A aires Financières—Directorate of Financial A airs DESR Division des Equipements Sanitaires et de la Réglementation—Division of Health Equipment and Regulation DNS Direction Nationale de la Santé—National Directorate of Health DPM Direction de la Pharmacie et du Médicament—Directorate of Pharmacy and Drugs DRH Direction des Ressources Humaines—Directorate of Human Resources FEMATH FEdération Malienne des Associations de Thérapeutes Traditionnels et Herboristes—Malian Federation of Associations of Traditional Thera- pists and Herbalists FENASCOM FEdération NAtionale des Associations de Santé COMmunautaire— National Federation of Community Health Associations

xxi xxii Acronyms and Abbreviations

FMPOS Faculté de Médecine, de Pharmacie et d’Odontostomatologie—School of Medicine, Pharmacy, and Dentistry GPSP Groupe Pivot Santé Population—Population Health Groupe Pivot (group of NGOs) INFSS Institut National de Formation en Sciences de la Santé—National Educa- tion Institute for Health Sciences INRSP Institut National de Recherche en Santé Publique—National Research Institute for Public Health INSTAT Institut National de la STATistique—National Institute of Statistics IS Inspection de la Santé—Inspection of Health OOAS Organisation Ouest-africaine de la Santé—West African Health Organization PDES Projet pour le Développement Economique et Social—Project for Eco- nomic and Social Development PDRHS Politique de Développement des Ressources Humaines pour la Santé— Human Resources Development Policy for Health PMA Paquet Minimum d’Activités—Minimum health care package PPM Pharmacie Populaire du Mali—Malian Popular Pharmacy PPP Partenariat Public-Privé—Public-private partnership PRODESS PROgramme de Développement Sanitaire et Social—Health and Social Development Program PSNRSS Plan Stratégique National de Renforcement du Système de Santé— National Strategic Plan to Reinforce the Health System PTF Partenaires Techniques et Financiers—Technical and Financial Partners RAMED Régime d’Assistance Médicale—Medical Assistance System SYNAPO SYndicat National des Pharmaciens d’O cine—Union of Pharmacists (working in pharmacies) TS Technicien de Santé—Health Technician TSS Technicien Supérieur de Santé—Superior Health Technician UEMOA Union Economique et Monétaire Ouest-Africaine—West African Eco- nomic and Monetary Union (WAEMU) UTM Union Technique de la Mutualité Malienne—Technical Union of Malian Mutual Insurance System (mutuelles) WAHO West African Health Organisation

Note: Throughout this report, the names of French organizations, titles, and institutions are translated into English but the acronyms, when used, correspond to the French. 1. Introduction and Background Elements

The “Health in Africa” Initiative

he many e orts to improve health in Sub-Saharan African countries in recent years Thave led to important progress in the availability and accessibility of health care. However, those improvements were uneven and occurred mainly in the public system, particularly in access to and delivery of health care services. All national and international players acknowledge more and more the contribution of private health care to public health care objectives in Sub-Saharan Africa. In those countries, the state is not in a position to meet the needs of its inhabitants. Gradually, the private sector has become an inevitable and dynamic player, in some instances now accounting for 40 percent to 50 percent of the system. This development occurred even as some public activities inhibited medium-term growth of private activities (for instance, through decisions to supply some medicines and services free of charge) and despite the fact that the private sector is, in most cases, only marginally integrated in public health improvement plans. Conversely, the state can play a decisive role, if it wishes, in the development of nongovernmental players. In some areas depending on the circumstances, the public authorities could decide to become involved again and decrease the weight of the private sector. To do so, governments have several instruments at their disposal (such as regulation, implementation of a self-regulation framework, funding, information). Reinforcing collaboration between the public and private sectors is thus crucial to develop the di erent components of the private sector and to improve their contribution to public health objectives. In this perspective, International Finance Corporation (IFC) developed the “Health in Africa” initiative through which it gives states the means to Identify private sector development opportunities Improve the relationship between the private and public sectors Articulate action plans and support their deployment. The Malian government quickly volunteered to lead the rst analyses. In this context, an initiative has been launched to De ne a strategy and a set of recommendations for all participants (Malian government, local players, technical and nancial partners) to increase the private sector’s contribution to public health objectives Sensitize all participants to the priority given to the development of the private health care sector.

The Malian Context Demographics With a population close to 13.5 million, Mali has one of the highest rates of demographic growth—2.8 percent per year—and an average of 6.8 children per woman. The population will grow by almost 20 percent between 2010 and 2025, reaching 18.6 million inhabitants. The total population will thus have doubled in 30 years between 1995 and 2025 ( gure 1.1).

1 2 World Bank Working Paper

Figure 1.1. The Malian Population, by Age Group

20 18.6 0.7 60 + 16.8 0.6 15.0 15 0.5 13.3 8.3 20-59 0.5 11.8 7.2 0.5 10.5 6.3 10 9.5 0.5 5.5 8.7 0.4 4.7 0.4 2.1 15-19 4.1 1.8 3.7 1.6 3.4 1.5 2.3 10-14 1.4 2.1 1.2 1.9 5 1.0 1.7 0.9 1.5 1.2 1.4 2.4 2.5 5-9 1.1 1.9 2.2 1.6 1.7 1.3 1.4 2.3 2.5 2.6 2.7 0-4 1.6 1.7 1.8 2.0 0 1990 1995 2000 2005 2010 2015 2020 2025

Source: Population Division, Department of Economic and Social A airs, United Nations Secretariat, World Population Prospects: The 2008 Revision. h p://esa.un.org/unpp.

The population lives mainly in rural areas (73 percent). Twenty-seven percent of the people live in urban areas, mostly in Bamako and regional administrative centers (Kayes, Sikasso, Segou, Mopti, and Gao).

Economic and Social Situation Table 1.1 presents basic economic indicators on Mali.

Table 1.1. Mali: Economic Indicators

Indicator 1987 1997 2007 GDP (billion U.S. dollars) 1.9 2.5 6.9 Exports / GDP 16.6% 26.1% 27.3% Debt / GDP 106% 127.4% 24.5%a ODA / inhabitant (USD current) — — 16b

Source: World Bank Mali at a Glance, 2008. h p://devdata.worldbank.org/AAG/mli_aag.pdf. a. 2006 data. b. 2008 data, (DAC, OECD)

Mali ranks 178th out of 182 in the United Nations Human Development Index (UNDP 2009): Human Adult literacy rate Combined schooling rate for GDP per Development Life expectancy (% of the population primary, secondary, and post- inhabitant Index (HDI) at birth (years) 15 years and older) secondary education (%) (PPP USD) 0.371 (178) 48.1 (165) 26.2 (151) 46.9 (162) $1,083 (162)

Source: UNDP 2009. Private Health Sector Assessment in Mali 3

General Business Climate for the Private Sector Health professionals su er from an ill-functioning private sector, even though the overall business environment is improving (table 1.1). According to Doing Business 2010, Mali ranks 156th (out of 183), a year-to-year gain of 6 ranks ( gure 1.2).

Figure 1.2. How Mali Compares with the Average of All Sub-Saharan African Countries

200

158 156 150 150 139 147 139 135 123 127 117 119 120 117 117 126 113 112 100 100 94 99 Score

0 Ease of Starting a Dealing Employ- Registering Getting Protecting Paying Enforcing Closing a doing business with ing property credit investors taxes contracts business business construction workers permits Mali score Sub-Saharan Africa average

Source: World Bank 2010.

Table 1.2. How Mali Ranks, Selected Indicators

Indicator Score Starting an activity (rank) 139 Number of procedures 7 Lead time (days) 15 Obtaining a loan (rank) 150 Index of creditors and borrower rights (scale of 1 to 10) 3 Index of loan information quality (scale of 1 to 6) 1 Paying taxes (rank) 158 Enforcing contracts (rank) 135 Number of procedures 36 Lead time (in days) 626 Source: World Bank 2010.

Compared with other Sub-Saharan African countries, the most penalizing factors in the general business climate are access to bank loans and payment of taxes. Conversely, compared with other Sub-Saharan African countries, Mali ranks well in the granting of licenses.

Health Conditions Thanks to the e ort undertaken by all players, the health conditions of the Malian population have improved over the last 15 years. The improvement is illustrated by signi - cant decreases in key indicators: from 237 percent in 1996 to 191 percent in 2006 in the infant-child mortality rate and from 582 per 100,000 in 2001 to 464 per 100,000 in 2006 in the maternal mortality rate. Despite this progress, the situation is still troubling. Close to 4 World Bank Working Paper one child in ve dies before the age of ve, and life expectancy at birth is 48 years (Hu- man Development Index UNDP).

Architecture of the Malian Health System The Malian health system is organized according to the health and population sectoral policy directives. The organization of public health care is pyramidal, with four levels. The rst level is the health district. Currently, there are 59 health districts, each divided into catchment areas with a CSCOM that o ers the minimum package. A community health association manages each catchment area. The CSCOM is the base of the pyramid, the rst point of contact. (In mid-2009, more than 900 CSCOMs were active in a total of 1,030 catchment areas.) At the second level, each district has a referral health center (CSREF), equipped with a more substantial technical platform and more highly quali ed personnel to take charge of cases referred by the CSCOMs. It thus completes the function of the health district, or “ rst referral” level. There are about 250 private practices. At the third level are seven “second referral” public hospitals, usually located in the regional capitals, which receive patients referred by the CSREF. There are also 70 private hospitals. The highest level consists of four “third referral” public hospital institutions, two of them generalists and two specialized. The schematic correspondence between private and public providers is roughly described in gure 1.3).

2. Private Health Care under the Malian System

The private health care sector in Mali is a result of reforms introduced in the second half of the 1980s.

History Figure 1.3. The Organization of the Health Since those reforms, the system has System greatly evolved under the combined e ects of the liberalization of Public Private the private practice of health professions and the Bamako initiative. University Hospital

1985–86: Liberalization of Private Medicine Public hospital Private hospital Since 1964, the system implemented by Malian authorities, partly in- CSREF Physicians' offices spired by socialism, was based on CSCOM The quasi-exclusive role of the state in health care pro- Traditional vision and drug distribution Therapists A policy of free health service. Source: BCG analysis. Private Health Sector Assessment in Mali 5

Under the structural adjustment programs, state budget cuts led the Malian authorities to stop recruiting graduate health professionals for the public sector. Mali then authorized, through Law 85-41 of June 22, 1985, the private practice of health professions.

1987–89: The Bamako Initiative The three main objectives of the Bamako initiative inspired Mali’s health policy: access to essential drugs, reinforcement of primary health services, and community participation in local management of health services, especially cost recovery. In this context, community health centers (CSCOMs) were set up, beginning in 1989 with its rst provider, the Banconi Association of Community Health (ASACOBA), in the Bamako district.

Health Policy in Mali The Sectoral Approach Supported by the donor community, Malian health policy is framed by Various programming documents, in particular, the Strategic Framework for Growth and Poverty Reduction (CSCRP) 2007–11 The coordinating support mechanism, The Health and Social Development Pro- gram (PRODESS), extended until 2011 to coincide with the CSCRP. The PRODESS became the reference document for the coordination, monitoring, and assessment of all partners. It includes a multiannual budget-building framework with all technical and nancial partners (PTF), as well as for all monitoring entities at national, regional, and local levels. The PRODESS includes the following developments and objectives for the social sectors: Project for the Economic and Social Development (PDES) of the President of the Republic Decennial Plan for the Achievement of the Millennium Development Goals (MDG) 2006–2015. The main indicators of the Malian Health Policy are described in box 2.1.

Box 2.1. Main Indicators of the Malian Health Policy

The main indicators of Malian health policy are: • Percentage of underweight children under the age of 5 (MDG 1) • Mortality rate of children under 5 (MDG 4) • DTCP vaccine coverage among children under 1 year of age (MDG 4) • Maternal mortality rate (MDG 5) • Rate of attended baby deliveries, including by retrained traditional midwives [accoucheuses traditionnelles recyclées] (MDG 5) • Prevalence of the HIV/AIDS virus among pregnant women 15 to 24 years of age (MDG 6) • Percentage of the population living within a 15 km of a functional health center • Antenatal consultation coverage

Source: PRODESS, Malian Ministry of Health. 6 World Bank Working Paper

Articulated with the PRODESS, other documents are also being prepared. They include: The Human Resources Development Policy for Health (PDRHS) The National Strategic Plan to Reinforce the Health System (PSNRSS), and A document on public-private partnerships. (This is in a preliminary stage. It tries to involve the commercial private sector more closely in a contractual framework for cooperation with the administration, while nongovernmental organizations (NGOs) and community health providers are already bound with the state through agreements.)

Decentralization/Deconcentration Policies Since early 2000, the Malian government has followed a policy for decentralization/ deconcentration of key services: education, water procurement, and health. Respon- sibilities, as well as skills and resources, are being progressively transferred to local communities. Primary health care services have already been turned over to local authorities. Now, the town councils intervene rst to support the ASACOs and CSCOMs. However, the e ective transfer of skills and resources is still slow.

Health Care Delivery

Private sector health care in Mali is delivered through di erent players: the CSCOMs, rural practitioners, and urban practitioners (private practices and hospitals).

Primary Health Care Services The CSCOMs are private entities that ful ll a public service mission, with strong support from the public authorities. The CSCOMs are nonpro t organizations, created by the communities grouped in ASACOs at the catchment area level.1 CSCOMs are tasked with delivering a minimum health package (PMA) of curative, preventive, social, and promotional services. They are funded by Cost recovery (health care service prices xed within the community, margin of about 15 percent on pharmaceutical sales) Contributions from the communities Subsidies from public authorities or NGOs. In this study, CSCOMs are considered private health care players. They are a unique feature of Malian primary care delivery. They form the base of the health pyramid and represent 56 percent of the contacts with conventional health care providers (0.23 contact/person/year on average). The ASACOs own and manage the CSCOMs in association with the technical head of the health center. Under the decentralization policy, the ASACOs sign a mutual assistance agreement with the town councils, de ning the modalities of the support to be provided to the health center. The state also provides support for the creation of centers (e.g., construction of premises, initial equipment) and throughout their activity. The CSCOMs globally achieve an estimated turnover of CFA F 30 billion and receive CFA F 23 billion in subsidies (40 percent nancial subsidies, 60 percent subsidies in personnel). Private Health Sector Assessment in Mali 7

An Extensive Territorial Network By mid-2009, the network of about 900 CSCOMs covered almost 90 percent of health areas de ned in Malian sectoral policy. Outside of Bamako, 87 percent of the population is located within 15 km of a CSCOM and 51 percent within 5 km. To date, 90 percent of the catchment areas (1,070 in all) have a CSCOM, whose rate of creation accelerated since the end of the 1990s ( gure 2.1).

Figure 2.1. Evolution of CSCOM Accessibility

79% 80% 80 75% 76% 69% 71%

60 58% 58% 50% 51% 46% 47% 40 Percent

0 2003 2004 2005 2006 2007 2008 Accessibility rate within a 5 km radius Accessibility rate within a 15 km radius

Sources: Statistical Directory 2009; health map—Bilan C les 2008 DNS CPS; interviews, BCG analysis. Note: Data for Bamako are excluded from this analysis.

This fast progression Figure 2.2. Population within 15 km of a CSCOM results from the deliber- (percent) ate policy to improve rural dwellers’ geographical accessibility to health services ( gure 2.2). It is a signi cant success for public policy. Some CSCOMs, however, have opened although they do not meet viability criteria, in particular in terms of population pool.

Private Medicine

Nearly half of all physi- % of the population within 15 km radius 60-70% cians in Mali have their 70-80% main practice in the pri- 80-90% More than 90% vate sector. Because the public sector cannot employ all newly graduated Sources: Bilan C les; BCG analysis. Note: CSCOM excluding Gao. 8 World Bank Working Paper

Figure 2.3. Distribution of Physicians, by Main Practice Location, 2008

2,500 118 2,546 284

2,000 400

431 1,500

100 200 1,000 350 Number of physicians

500 500

0 Office Private CSCOM Others Public CSREF Central DRS Total hospital (NGO, INPS) hospital and similar

Sources: Ministry of Health (data 2008); BCG analysis. Note: Assumption of two physicians per o ce and ve physicians per private hospital. physicians, the number of private practitioners is growing every year. Private practitioners represented around 48 percent of all physicians in 2008 ( gure 2.3).

Rural Practitioners Less than 10 percent of all physicians practice in a rural environment. Partly grouped within the rural physician association (AMC) and supported by the programs of the Santé Sud association, rural practitioners consist of Physicians (about 200) working in a CSCOM, according to the Human Resourc- es Directorate of the Ministry of Health Family physicians (about 30) with their own practice and physicians employed by religious/associative providers, according to the AMC). Most private family physicians have less access to technology than do their urban colleagues. Some of them have an echograph, but rarely do they have even a small laboratory for medical analyses.

Urban Practitioners Private practices and hospitals are the main medical providers in urban areas. The main types of private health institution are medical practices for outpatient care and private hospitals for inpatient care. Private hospitals can be further di erentiated by the nature of health services they are authorized to render: medical hospitals and surgical hospitals. Most medical practices o er generalist health care services. The most important among them, such as private hospitals, o er specialty services usually delivered by publicly employed specialists who go to the private hospital as outside specialists to deliver a speci c service. This double activity is common among public doctors. Private Health Sector Assessment in Mali 9

The technical platform of the best-equipped private hospitals does not reach the level at cu ing-edge public hospitals, but it is sometimes comparable to the level at second-referral hospitals, and thus completes the technical platform available at territorial level. Pasteur private hospital is a special case; its superior equipment and number of specialists make it a referral center in Bamako, especially for wealthier people. The number of practices in Mali is estimated at 250, and the number of private hospitals at 70. A practice usually has two full-time physicians. The smallest practices employ only one; the largest, ve or six people. A private hospital usually has ve physicians; the smallest, three or four people. The biggest private hospitals in Bamako can have 20 to 25 health care professionals. Box 2.2 lists some typical fees.

Box 2.2. Some Typical Fees

The following prices are charged in Dr. Koné’s private hospital in Niono (CFA F): • Consultation: 2,000 • Echography: 8,000 • Analysis: 3,000 • Light surgery: 2,500 • Birth: 20,000 • Hospitalization: 2,000 a night

Source: BCG interview.

Private providers represent, at the national scale, a contact rate of 0.1/person/year ( gure 2.4). There are also a few private nursing practices and private midwife practices.

Figure 2.4. Contact Rate, by Provider Type

0.5

0.4 0.10

0.3

0.2 0.23 0.41 Contact rate/capita/year

0.1

0.08 0.0 Public establishments CSCOMs Private establishments Total

Sources: SLIS 2008, 2007; DNS; CPS; Bilan C les: BCG analysis. 10 World Bank Working Paper

Uneven Regional Distribution of Private Providers The estimated distribution of private providers, in the absence of an o cial census, is 70 percent in Bamako and 30 percent in the regions (table 2.1).

Table 2.1. Private HC Provider Geographic Distribution

Provider Bamako Regions Total Practices 175 75 total, located in 250 • Kayes, Koulikouro, Segou, and Mopti (10 to 15 practices) • Gao, Kidal, and Timbuktu (2 to 5) Private hospitals 49 21 total, located in 70 • Kayes, Koulikouro, Segou, and Mopti (3 to 5) • Gao, Kidal and Timbuktu (0 to 1)

Source: BCG analysis.

Such a distribution of health care providers represents: Practices: 1 practice for 7,700 inhabitants in Bamako, 1 practice for 156,000 inhabitants in the rest of the country, and 1 practice for 52,000 inhabitants for the whole of Mali. Private hospitals: 1 private hospital for 27,700 inhabitants in Bamako, 1 private hospital for 557,000 inhabitants in the rest of the country and 1 private hospital for 186,000 inhabitants for the whole of Mali.

Informal Market for Medical and Paramedical Care The informal health care provision sector involves physicians, as well as health care technicians (nurses, midwives). It encompasses three main types of situations: Young physicians or (superior) health care technicians searching for an activity at the start of their careers, especially in Bamako with its high concentration of health care professionals Retired nurses and midwives who continue to practice at home or on house calls People trained in health care for various reasons (e.g., former undergraduate students of health care schools) o ering their services without o cial quali cation. In the rst two instances, the informal activity is essentially transitional.

Service Quality and Equity The mechanisms for regulating quality of privately provided services include administrative controls and self-regulation within the National Physicians Association (Ordre des Médecins). Quality breaches in the private sector are not always reprimanded, due to the limited means for administrative control and the di culties professional associations have enforcing discipline. Incentives to comply with quality standards are on the rise, however, as the sense of medical responsibility increases and the perception that legal actions against health care personnel are becoming increasingly frequent. In addition, the implementation of compulsory health insurance should be considered a new incentive for accredited institutions to improve quality. The inclusion of private institutions in the AMO would help reinforce demand for higher quality. Services in the private commercial sector are priced higher on average than the of- cial price charged by publicly subsidized providers (table 2.2). Private Health Sector Assessment in Mali 11

Table 2.2. Average Cost and Cost Structure of Health Care Services, by Provider

Traditional Family Itinerant Public Medical Private Item practitioner CSCOM member healer CSREF Other hospital practice hospital Cost (total in million CFA F) 3.35 8.31 10.33 14.54 15.12 18.10 25.13 27.21 28.31 Transport (% of total) 1.0 20.9 1.4 4.4 11.57 9.7 15.8 23.3 7.17 Drugs (% of total) 48.1 68.7 52.0 83.2 76.87 62.9 70.0 57.3 69.53 Consultation (% of total) 50.9 9.4 46.6 12.4 10.60 27.4 14.2 19.5 23.30

Source: Survey of 1,050 Malian households.

Analysis of the main features that in uence patient perceptions of the di erent types of providers2 indicates that private practices and private hospitals are considered of a bet- ter quality than CSREFs and public hospitals in terms of equipment quality, sta competence, cleanliness of the premises, and the quality of welcome and listening (table 2.3).

Table 2.3. Grades Given by Patients to Provider Performance on Evaluation Criteria

Traditional Traveling Medical Private Public Importance rank / criterion practitioner healer practice CSCOM CSREF hospital Hospital Ef ciency of recovery 3.71 2.57 3.95 4.11 4.36 4.60 4.68 Appropriate distance 3.72 2.97 3.27 4.17 3.49 3.37 3.15 Appropriate consultation price 4.10 3.11 3.07 3.87 3.81 2.84 3.55 Appropriate prescription price 4.10 3.15 3.13 3.55 3.61 2.90 3.36 Drug availability 3.90 2.97 3.10 3.70 3.91 3.58 4.04 Quality of welcome and listening 3.43 2.44 3.8 3.96 3.82 4.23 3.90 Equipment quality 2.77 2.28 3.64 3.25 3.80 4.37 4.43 Cleanliness of premises 2.89 2.36 4.03 3.78 3.71 4.61 3.85 Staff competence 3.69 2.48 3.9 3.96 4.24 4.37 4.47

Source: Survey of 1,050 Malian households.

Education of Health Care Professionals

Two types of health care professional are trained in Mali: physicians and pharmacists trained at Bamako University and health care technicians trained at public institutions and private schools.

Education of Physicians and Pharmacists Physicians and pharmacists are educated at the University of Medicine, Pharmacy, and Dentistry (FMPOS), run by the Bamako local education authority. The creation of a second University of Medicine, in Segou, is under study. A private University of Medicine was authorized to start its activities in Bamako in June 2009. Its promoters are seeking funding to create a 10-to-15-ha campus to prepare about 50 students a year for the national examination. Medicine would be the initial dis- ciplines taught. Tuition fees would be about CFA F 2 million/year/student versus CFA F 5,000 for FMPOS.3 The new university does not plan to educate pharmacists. The physician education policy for 2005–08 favored a high increase in the number of graduates, switching from between100 and 150 a year to between 300 and 400 a year ( gure 2.5). The establishment of a numerus clausus will allow stabilizing at 150 the number of graduates each year. 12 World Bank Working Paper

Figure 2.5. FMPOS-Educated Physicians (forecasts beyond 2010)

400

300

200

Number of physicians 100

0 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025

Sources: CDRH; FMPOS, BCG analysis. Note: Assumes 3 percent annual growth in the number of people trained starting in 2014.

Education of Health Care Technicians Superior health care technicians (TSSs4) and health care technicians (TSs5) are educated at private health care schools and public institutions (National Education Institute of Health Care Sciences, created in 2004 by the merger in 2004 of all public training schools). These private schools—the rst created in 1995—saw their numbers grow from 6 in 2004 to 41, in 2009. Forty-six percent of those private schools are in Bamako. In 2008, they graduated 53 percent of the candidates admi ed to TSS certi cation and 95 percent of

Box 2.3. Documents Needed for Authorization to Teach

Decree 94-276/PRM, Article 4 stipulates that the following documents must be presented to obtain an authorization to teach. About the Institution 1. Note to present to the institution (educational, professional, and social goal of the institution and about its utility in the framework of the country’s general interest) 2. Detailed plan of the premises and of health installations, all agreed upon by the housing service 3. Nature of the education or training to be provided in the institution About the Registrant 1. Copy of the birth certi cate or anything else that can serve as such 2. Certi cate of Malian or foreign nationality 3. Copy of any criminal record of less than three months old 4. Brief biographical note indicating the registrant’s antecedents of the last ve years, suc- cessive places of residence, and professions 5. For corporate bodies, a certi ed true copy of the statutes, articles of incorporation, and legal authorization to settle in Mali of the association, company, union, grouping of con- gregation represented by the registrant 6. Minutes of meetings of the board of directors of the organization that mandates the registrant 7. Proof that the registrant or the corporate body he/she represents satis es the settlement requirements for foreigners in Mali

Source: Authors. Private Health Sector Assessment in Mali 13 the candidates admi ed to TS certi cation, according to the Human Resources Director- ate of the Ministry of Health. There is no speci c law on the creation of private health care schools, which are under the authority of the ministry in charge of higher education. Those schools need consequently ful ll only the generic conditions of Decree 94–276/PRM for all private educational institutions. Moreover, authorization is granted automatically if the administration does not respond to an application within three months, according to Article 11 of the same decree.

Pharmaceuticals and Medical Products Distribution

Th is section describes the split between public and private distribution, the geographical distribution of pharmacies, the size of the drug market as well as illegal trade in pharmaceuticals.

Public-Private Split for Distribution Pharmaceuticals and medical products in Mali are distributed through public and private channels. The private channel has about 30 wholesalers-dispatchers and 363 pharmacies. The public channel has a public importer/wholesaler/dispatcher, the Malian Popular Pharmacy (PPM), and pharmaceutical depots of public and community providers (hospitals, CSREFs, CSCOMs).There are also some private pharmacy depots—retail outlets run by nonpharmacists in areas where there are no pharmacies. Complementarity between the two channels is ensured by allowing private wholesalers to serve public providers in case of stockouts at the PPM and to supply hospital providers with specialty drugs. An estimated 50 percent of demand from public providers is covered by private wholesalers ( gure 2.6).

Figure 2.6. Overview of Drug Distribution

Producer Dispatcher Importer Wholesaler Retailer Point of sale

Laborex 95% 5% Copharma 95% Pharma Private 5% 30% distribution Africalab and Camed 10% 90% Private distribution Other private wholesalers compensates for public distribution 100% if need be (stockouts, hosp. specialties) Hospitals = ~50% of market PPM and CSREF Public 10% distribution 100% CSCOMs

Main flow Specialties Secondary flow Generics

Source: Interviews; BCG analysis. 14 World Bank Working Paper

Geographical Distribution of Pharmacies Pharmacies are concentrated in the regional and local administrative centers. About 50 percent of them (190 out of 363) are located in Bamako). In addition to this concentration in Bamako, every large city (regional administrative centers) in Mali is saturated relative to the zoning rules or the minimum number of inhabitants required to obtain a license. This is why there is a waiting list in every region ( gure 2.7).

Figure 2.7. Waiting List for Licenses to Open a Pharmacy, by Region

250 220

200

150 Number of waiting pharmacists

100

Number waiting 90

50 23 25 15 10 3 1 0 Bamako Koulikouro Gao et Kidal Kayes Segou Sikasso Mopti Timbuktu

Sources: CNOP; INSTAT; BCG analysis.

Box 2.4. The Zoning Rules Governing Pharmacy Opening

Decree 98-0908 MSPAS SG, Article 1 prescribes the number of inhabitants required to open a pharmacy or a depot for pharmaceuticals: • One organization for 7,500 inhabitants in cities of 100,000 to 500,000 inhabitants • One organization for 6,500 inhabitants in cities of 10,000 to 99,999 inhabitants • One organization for 5,500 inhabitants in cities of fewer than 10,000 inhabitants

Source: Authors.

Size of the Drug Market The turnover of public and private wholesalers represents CFA F 45 billion (selling price). Private players, dominated by Laborex and Copharma, focused on specialty drugs, represent 80 percent of the market. The two other main wholesalers, Africalab and Camed, concentrate on generics ( gure 2.8). Private Health Sector Assessment in Mali 15

Figure 2.8. Pharmaceutical Sales by Private and Public Wholesalers (turnover at CFA F billion selling price)

0.9 0.1 Generics 1.1 0.5

Specialties 20.4 9.0 4.0 9.0

LaborexCopharma Other PPM wholesalers Africalab and Camed

Sources: Ou ara et al. 2004; interviews with distribution players; BCG analysis and modeling. Note: Data 2008. Hypotheses: estimated sales at the selling price of main players—1.2 multiplying coef- cient applied by all wholesalers based on cost price sales (specialties and generics included).

The drug price structure, though free in theory, has actually been decided through consultations among players since the devaluation of the CFA F in 1994.

Illegal Trade in Pharmaceuticals The illegal drug market has grown since the 1990s. In 2008, this market was estimated at CFA F 10 billion, 15 percent of consumption. This private black market operates throughout the country and encompasses every type of drug: specialties and generics, with and without marketing authorization, au- thentic and counterfeit (PRSAO 2008; interviews). This market thrives because it makes drugs easy to obtain and at lower prices. It contributes to the overall nancial accessibility of drugs. The illegal drug market bene ts from complicities. Shopkeepers, public servants, health care professionals, and in uential personalities play roles of varying importance. Pharmaceutical stakeholders, public and private, sometimes participate. Pharmacies may buy on the illegal market or sell their own stock. Wholesalers without known o - cial activity (more than half of the 30 wholesalers) are suspected of supplying the illegal market. Indeed, today’s requirements for obtaining a wholesaler license are not being met— having su cient supply to cover the monthly consumption of the pharmacies served; carrying stock that represents two-thirds of the products that have received market authorization; and being able to deliver drugs to client pharmacies in 72 hours. 16 World Bank Working Paper

Pharmaceutical Manufacture With the exception of herbalists, there is no national production capacity. The Malian Pharmaceutical Production Plant (UMPP) has undergone a strong reduction in its capacity and is no longer considered capable of manufacturing anything but a few medical products (serum).

Health Insurance

The 2005–09 National Plan set the objectives of extending social insurance protection (AMO), and social support (RAMED) though the Medical Assistance Fund (for the des- titute). These two regimes were created in 2009, and the application decrees are being prepared. AMO will cover 16 percent of the population, essentially formal sector em- ployees and civil servants. RAMED, intended for the very poor, should cover 5 percent of the population Funding is not weighted equally for these three types of social protection (health insurance, social support, mutual insurance). The AMO was developed rst ( gure 2.9).

Figure 2.9. Scheduled Funding for the Social Protection Extension Plan, 2005–09

20,000

15,000 13.3

10,000 12% of 19.7 scheduled funding F CFA billion F CFA

5,000 4

2.3 0 Mutual benefit companies Social aids and action Social security Total

Source: Ministry of Social Development 2009b.

Private Mutual Insurance Mali implemented a legal framework to favor the development of private mutual insurance: Law 96–022 governs mutual insurance. Decrees 96–136 and 137 sets requirements for the fund investment and deposit of the mutual and sets the statutes of mutual insurance. The institutional framework of the mutual insurance movement was consolidated with the creation, in 1998, of the UTM, a towering provider that exercises both a representation and advocacy role, and a centralized managerial role, for some a liated mutual insurance. Private Health Sector Assessment in Mali 17

The objectives set in the national plan for extending social protection in 2005–09 include covering about 3 percent of the population under mutual insurance regimes. In 2008, the coverage rate was close to 2 percent, according to the Ministry of Social Develop- ment, with 76,667 subscribers and 244,028 bene ciaries, 70 percent of them in Bamako. In 2008, there were 121 chartered mutual insurance companies (health and retire- ment/death services combined, gure 2.10). Beyond Bamako, where the average number of bene ciaries reaches 45,000, those risk-sharing entities have an average bene - ciary base of between 800 and 1,800 members.

Figure 2.10. Growth of Private Mutual Insurance Entities and Bene ciaries (numbers)

Evolution of the number of Number of beneficiaries of Average number of authorized mutual benefit mutual health companies per beneficiaries per mutual companies1 region company per region

121 164,609 4,703 Bamako The average size of mutual companies is 99 represents 67.5% of beneficiaries lower than the viability threshold of 3,000 beneficiaries 77 28,117

60 19,787 2,160 1,849 44

1,041 9,040 7,851 989 904 981 7,397 807 788 5,652 1,575

2004 2005 2006 2007 2008 Bamako Segou Gao Koulikouro Bamako Segou Gao Koulikouro Sikasso Kayes Mopti Timbuktu Sikasso Kayes Mopti Timbuktu

Sources: DNPSES 2008: BCG analysis. Note: Health and other services included (pension/death), threshold as generally estimated by the UTM.

Clinical Pathway

An opinion survey involving 1,050 Malian households was conducted by BCG early in the project to nd out about Malian patients’ clinical pathway. As a target for health facility consultation rates, 120 percent6 was used ( gure 2.11). Among the ndings were: Sixty-three percent of health service subscribers forgo treatment. Reasons given include patient estimates that his/her state of health does not justify treatment as well as situations in which nancial or other factors preclude treatment). The self-medication rate is 15 percent (8 percent taking traditional herbs, 7 percent modern drugs). The advice-seeking rate is 42 percent (41 percent at conventional facilities, hypothesis of 1 percent from traditional practitioners).7 The same survey allows tracking of the clinical pathway of patients looking for advice to cure themselves ( gure 2.12): Small numbers of people seek advice from traditional practitioners. (Three percent rst go to traditional healers when seeking advice; 13 percent when seeking advice the second time.) These numbers seem understated in the survey. 18 World Bank Working Paper

Figure 2.11. Advice-Seeking versus Self-medication: Patient Behavior in Response to Health Problem

150 Purchased herbs 120 63 Looked for herbs Medicine in 100 illegal pharmacy (“pharmacie par terre”) Medicine in a Rate in % 15 3 pharmacy 50 3 5 4 42

0 Morbidity rate Non-treatment Self-medication Consultation rate

Sources: Survey of 1,050 Malian households; BCG analysis. Note: The consultation rate integrates prenatal care—contribution estimated at 8 percent. Hypotheses: Target level = one consultation per illness episode, i.e., a consultation rate of 120 percent. The gap should be even larger when an illness generates more than one consultation.

For rst visits, the CSCOM is the most frequented type of facility, with 58 percent (81 percent in rural areas and 40 percent in urban areas). Private commercial facilities see an increase in visits between the rst and second consultations: 3 percent to 5 percent for a medical practice; 7 percent to 17 percent for a private hospital ( gure 2.12). Breaking down the clinical pathways by household revenues reveals that the choice of going to CSCOMs or private hospitals is connected to patients’ nancial situations ( gure 2.13).

Figure 2.12. Breakdown of Health Providers, by Consultation

3% 3% 1% 3% 2% 100 6% 13% 17% 80 5% A member of your family 17% A traditional practitioner 58% 60 33% An itinerant practitioner 19% A medical office

Percent A CSCOM 40 17% A CSREF 8% A private hospital 20 7% 44% A public hospital 23% 17% Other 0 1% 3% 0 250 500 750 1,000 1,250 1,500 1,750 2,000 2,250 Number of occurrences 1st resort 2nd resort 3rd resort

Sources: Survey of 1,050 Malian households; BCG analysis. Private Health Sector Assessment in Mali 19

Figure 2.13. Choice of Providers Depends on Household Income

100 3 3 2 4 0 0 3 4 1 5 A member of your family 1 5 2 1 1 1 5 3 4 0 A traditional practitioner An itinerant practitioner 80 A medical office 32 30 A CSCOM 43 A CSREF 60 63 56 A private hospital 9 17 A public hospital Other

Percent 9 40 12 19 35 10 7 20 5 5 26 23 13 16 12 5 0 2 0 2 1 Less than From 500,000 From 1,000,000 From 2,000,000 More than Income 500,000 CFAF to 1,000,000 to 2,000,000 to 3,000,000 3,000,000 per year CFAF per year CFAF per year CFAF per year CFAF per year

Sources: Survey of 1,050 Malian households; BCG analysis.

The consultation rate at CSCOMs is 63 percent for households with annual revenues lower than CFA F 500,000, versus 30 percent for households with annual revenues of more than CFA F 3 millions. The consultation rate at private hospitals is 5 percent for households with annual revenues lower than CFA F 500,000, versus 30 percent for households with annual revenues higher than CFA F 3 millions The whole population, including the poorest people, uses some component of the private health care sector (CSCOMs for the poor populations, private hospitals for richer populations).

Synthesis: Sizing the Health Care Sector

All health care expenditures at country level have grown substantially over a period of almost 15 years ( gure 2.14). Almost 50 percent of all health expenditures throughout the system (including all support functions) are paid out of pocket (CFA F 108 billion in 2008). Table 2.4 presents a breakdown of health care expenses in Mali. This corresponds to annual average expenditures of about CFA F 8,000 per capita, almost 65 percent of it on drugs. Spending on traditional products and traditional consultations is not included in those numbers. Their informal and potentially nonmonetary nature (such as compensation in-kind) makes their estimation di cult. The private sector represents more than half of the health care system. For the health care delivery channel, 80 percent of curative consultations occur in the private sector and 50 percent of physicians practice in the private sector. For the pharmaceutical channel, 80 percent of the turnover at selling price is achieved in the private sector and 50 percent of the needs of public facilities are covered by private wholesalers. 20 World Bank Working Paper

For the education channel, about 50 percent of students admi ed to TSS examinations are educated in private schools, and about 90 percent of students admit- ted to TS examinations are educated privately. For the health insurance channel, All mutual insurance entities are private.

Figure 2.14. Growth of Health Expenditures in Mali

250 239 222 207 200 194 7.5% 175 Public 165 122 expenditure 153 115 108 150 141 140 97 119 86 68 81

CFAF billion CFAF 109 64 56 94 95 98 100 33 39 37 44 40 117 Private 50 98 99 108 expenditure 77 80 78 84 86 84 90 50 55 61 0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Year

Sources: WHO n.d.; Malian National Health Expenditures, h p://www.who.int/nha/country/mli/en/; BCG Projections for 2008 and 2009.

Table 2.4. Breakdown of Health Expenses in Mali, 2008

Provider/type of 2008 amount expenditure (CFA F billion) Comments Drugs 70 Based on the analysis of the pharmacy value chain, taking into account the illegal market: CFA F 45 billion at wholesalers’ selling price with a public-private retailer gross margin of 30 percent on average and expenditures associated with the illegal market of about 15 percent of the total CSCOMs 15 On an estimated turnover of 30 CFA F billion, including drugs, with subsidies (excluding drugs) (including personnel made available) estimated at CFA F 23 billion CSREF 0.4 For the 59 CSREFs, 400,000 annual consultations charged in 2008 with an average price of CFA F 1,000 Hospitals 4 About 675,000 annual consultations with an average price of CFA F 6,000 Private practices 7 Of the 250 registered private practices, an estimated 900,000 consultations charged at CFA F 7,800 on average. Private hospitals 8 About 500,000 annual consultations for 70 institutions with an average price about CFA F 16,000. Not explained 4

Sources: BCG primary studies, consolidation of sources (SLIS 2008, 2007; Bilan C les). Private Health Sector Assessment in Mali 21

3. Governance, Regulation, and the Business Environment

his section covers the role of the private sector in the governance of the health sys- Ttem, private sector regulation, and the business environment. Associating the Private Sector in Governance of the Health System

Despite its ever-growing role in health care delivery, the private sector is poorly integrated in Mali’s policy-making centers. Of the two private streams, the community private health sector is more closely integrated in the policy process than the commercial and traditional private sector.

Perceived Legitimacy of Private Sector The private sector developed out of necessity after the government was forced to relin- quish its role as sole health provider in Mali. The circumstances surrounding the birth of the private sector still taint its legitimacy. The private commercial sector is often perceived to be motivated by pro t to the detriment of the peoples’ health and well-being. Conversely, the public sector is imagined to be more sensitive to equity and accessibility considerations for the people most in need of medical a ention. The health sector in Mali, as in many other countries, is symbolically dominated by the medical profession. In the public sector, the prestige and intellectual authority of medical professors, teachers at the FMPOS, and service managers in third-referral hospitals all feed a public sector superiority complex, a sort of “VIP system.” This perception is all the more acute because failure in the competitive examinations for public service often relegates would-be public physicians to private practice.

Integration of the Private Sector in the PRODESS National Monitoring Bodies The PRODESS monitoring entities constitute the design and strategic programming center for health care policy in Mali. The commercial private sector, as opposed to the private associative sector (GPSP) and civil society (UTM), is not represented in the national monitoring bodies, the steering commi ee, or the technical commi ee. Conversely, “a representative of the private and religious health facilities” is seat- ed with “representatives of NGOs in the health and social action sector” and a health representative of the regional/local communities within regional and local PRODESS monitoring entities: regional commi ee to direct, coordinate, and assess the PRODESS (CROCEP), and a management council.

Institutionalization of the Administration–Private Sector Dialogue Dialogue between the public sector and the private sector is mainly informal—at confer- ences, seminars, and training sessions and within the Professional Councils. Though not a unique referent for the private sector, the DNS division in charge of contracts and public-private partnerships (DESR) has been progressively reinforced since 2006. 22 World Bank Working Paper

Box 3.1. The Policy-Making Bodies for the PRODESS

The following are excerpts from Decree 01–115/PM-RM of February 27, 2001, on the creation of the bodies to direct, coordinate, and evaluate the Health and Social Development Program. “Article 3: The steering committee is composed as follows: “Presidents: The ministers in charge of health care and social development; First vice president: A representative of development partners; Second vice president: A representative of the civilian society. Members: • The representative of the minister in charge of nances; • The representative of the minister in charge of foreign affairs; • The representative of the minister in charge of education; • The representative of the minister in charge of the promotion of women, children, and family; • The representative of the minister in charge of the territorial administration; • The representative of the minister in charge of the environment; • The representative of the minister in charge of energy; • The representative of the minister in charge of youth; • The representative of the minister in charge of communication; • The directors of central services of the ministries in charge of health and social development; • The general manager of the Malian plant of pharmaceutical products; • The general manager of the Popular Pharmacy of Mali; • The representatives of the development partners; • A representative of the Groupe Pivot Santé Population; • A representative of the Malian Federation of the Associations of Disabled People; • A representative of the National Council of Aged People; • One representative per Professional Council of health care professionals; • One representative per union; • The national coordinator of readaptation on community basis; • The representative of the technical union of private mutual insurance.

“Article 4: The Committee can call upon any person due to his/her particular skills.”

Source: Authors.

Organization of the Private Sector The private sector is organized around Professional Councils, unions, councils and associations.

THE PROFESSIONAL COUNCILS The three Professional Councils consist of all health care professions. They were created by law in 1986 to serve as a framework for self-regulation of the health professions, which liberalization removed from the hierarchical authority of the Ministry of Health: Ordre des Médecins (National Physicians Council) Ordre des Pharmaciens (National Pharmacists Council) Ordre des Sages-Femmes (National Midwives8 Council). Private Health Sector Assessment in Mali 23

The Professional Councils do not have a representative or defensive role for private sector interests, not even when their members, such as pharmacists, operate mostly outside the public service.

INTEREST GROUPS: COUNCILS, UNION FEDERATIONS To exercise an advocacy role, part of the private sector is organized around an umbrella council or federation: The community private sector is grouped within the FENASCOM. The associative private sector is grouped within the Groupe Pivot Santé Popula- tion (GPSP). The traditional private sector is grouped within the Malian Federation of As- sociations of Traditional Therapists and Herbalists (FEMATH). Mutual insurance arrangements are, for the most part, represented by the UTM. The commercial private sector is represented by a variety of sectoral organizations, including: For physicians. Association of Physicians in Private Practice in Mali, Association of Rural Physicians For pharmacists. National Union of Pharmacists, Collective of Young Pharma- cists, Association of Diagnostic Laboratories For paramedical professionals.9 Nurses Association, Midwives Association For health care schools: Association of Private Health Care Schools. The extent of representation of those associations is more or less established. In the absence of permanent sta and due to limited resources, their capacity to circulate information to their members is limited, and their in uence with public authorities is minimal. Those observations are also valid, but to a lesser extent, for Professional Councils. To deal with this situation, and following the commitments made during the August 2009 seminar, a collective of the di erent associations in the commercial and nonpro t private sector is being created.

Private Sector Regulation: Strategic Documents and Regulatory Framework

Health care strategic documents do not deal speci cally with the private sector, but a number of regulatory frameworks do.

Strategic Documents No strategic document, as such, deals with the private sector overall. The sector is sum- marily mentioned without any global perspective, in PRODESS II. However, several policy documents are being prepared on ways of improving the private sector’s contribution to public health objectives. A contracting guide between the public and private sectors has been in the works since 2003 with support from the World Health Organiza- tion (WHO) and the World Bank. That process led to the elaboration in 2007 of a contracting policy document in the sociosanitary sector.

Normative Framework The texts mentioned below are not an exhaustive inventory of norms in e ect. 24 World Bank Working Paper

COMMERCIAL PRIVATE SECTOR The main laws liberalizing the health care professions were adopted in 1985; the application texts, between 1989 and 1992. They are: Law 85–41/AN-RM concerning the authorization of the private practice of health professions Decree 89–2728/MSP.AS/CABn se ing the details of the granting of authorization of private practice of sociosanitary professions Decree 91–106/P-RM concerning the organization of the private practice of health professions modi ed by decree 92–106/P-RM Decree 91–4319/MSP.AS.PF/CABn se ing the modalities of the organization of the private practice of medical and paramedical professions Law 02–050 AN-RM organizes cooperation between private and public health facilities and their participation in public service missions.

PHARMACEUTICAL INDUSTRY The two main documents addressed to the pharmaceutical sector are not binding: Master Plan for the Supply and Distribution of Essential Drugs (SDAME) The national pharmaceutical policy of Mali. The zoning rules are de ned by Decree 98–0908 MSPAS SG (number of inhabitants required for a pharmacy or a depot). Pharmaceutical pricing is free in the private sector,10 except for a list of 107 essential drugs that are subject to ceilings. The relevant laws are: Decree 07–087 regulating essential drug prices in the private sector Decree 03–218 regulating essential drug prices in the public sector.

COMMUNITY PRIVATE SECTOR The texts supervising community health were adopted between 1994 and 1995. There is no law governing community health care. The main law is the Cross-ministerial De- cree 94–5092/MSSPA.MATS.MF se ing the conditions for the creation of the CSCOM and the management modalities of sociosanitary services in districts, towns, CSCOM, as amended by Cross-ministerial Decree 95-1262/MSSPA.MATS.MFC.

Business Environment

Access to credit, tax payment, and permits and licences delivery are considered barriers to the development of the private sector in health care.

Access to Credit Both credit availability and credit demand are underdeveloped.

CREDIT AVAILABILITY Due to the macroeconomic environment, Banks estimate that their long-term resources are limited, and interest rates are high (between 12 percent and 15 percent). In addition, because credit institutions are risk averse, Bank funding consists mainly of short-term, low-risk loans (such as lines of credit for shopkeepers). Young physicians just starting out in practice nd it di cult to obtain the required guarantees. Private Health Sector Assessment in Mali 25

Finally, most nancial institutions feel that the quality of loan applications led by health professionals, (lacking managerial training) is insu cient. Thus, bank lending to health professionals is sporadic—and rare for covering start-up costs. When these professionals are granted loans, however, credit institutions report good experience.

CREDIT DEMAND A credit culture is not highly developed in Mali, and health professional demand is low for funding through an intermediary. Young health professionals starting out on their own or with others frequently go to individuals (family, private investors) for the largest investments (private hospitals, schools).

Tax Payment Health care professionals’ main tax complaint is about the opacity of instructions for calculating them. Most health care professionals know li le about their eligibility for tax breaks. Regarding tax rebates, private health care professionals are wary of any information-forwarding system that they suspect of feeding information to the tax authorities. This partly explains their reluctance to participate in the health information system. Pharmacists speci cally resent the alignment of their tax rates on shopkeepers’ rates.

Permits and Licenses Average estimated lead times11 are three months to obtain a permit and then the license ( gure 3.1).

Figure 3.1. Average Lead Time to Obtain a Permit and a License

Lead time for a permit Lead time for a license

Max: 6 months Max: 12 months

Average: 3 months Average: 3 months

Min: 1 month Min: 3 months

Sour ce: BCG analysis.

Use of the one-stop shop of the Investment Promotion Agency (API) is a rarity: only three medical practices have used it since May 2008. It would simplify the licensing procedure by allowing simultaneous registration with the O ce of the Trade Court and with the Tax O ce. However, the existence of the API is barely known in the health care sector, especially in the private sector and, if known at all, it is misunderstood. Profes- sional Councils fear the one-stop shop might take the responsibility for examining re- quests away from them (veri cation of compliance with technical requirements). 26 World Bank Working Paper

Licensing requirements are demanding for young physicians. According to the professionals interviewed however, in the eyes of the administration, despite the laws, a permit confers a de facto temporary license. A license is required for employers, in order to pass the technical visit, to hire their sta using a permanent work contract. Employers perceive this requirement as too rigid and constraining.

4. Analysis of the Health System

nalysis of the health system must begin with a “systemic” point of view. The dif- Aferent facets of the Malian health care system are tightly interconnected, so that the development of one component drives the others. As an illustration, the expansion of health coverage allows payment for health services to be separated from utilization. The removal of the payment barrier to use automatically brings about an increase in visits to health institutions. This increased use raises turnover, which allows investment in quality resources (employment of physicians, equipment purchases). The perceived increase in quality prompts people to make be er use of their health coverage. This simple loop occurs in every part of the system ( gure 4.1).

Figure 4.1. Systemic Representation of the Health System

B Support to Improvement C viable CSCOMs of staff training and D Development of geographic Development of a health coverage A high-quality distribution private medicine

Improvement of E drug distribution

Evolution of the F clinical pathway Priority areas

G Reinforcement of public / private governance

Sour ce: BCG analysis.

The systemic analysis concludes that the best way of improving Malians’ health is to strengthen the community and rural health system and expand mutual insurance.

Private Medicine

Private medicine is characterized by: Uneven distribution nationally, which entails the limitation of the market’s absorption capacity, leads some providers, looking for business, to deliver lesser- quality services. Private Health Sector Assessment in Mali 27

Tenuous contact with the public sector limits private parties’ inclusion in the public service missions of education and vaccination and does not allow the exploitation of complementarity between private and public health facilities. Stakeholders challenge rules categorizing di erent types of health institutions that would penalize private sector contribution to the public health objectives. Support is lacking for funding and training needs during the start-up phase.

Glut in Bamako, Shortages Elsewhere About 7 out of 10 private physicians have practices in Bamako. Even limiting the potential market of commercial private providers to the urban population would leave distribution unbalanced, considering that only 4 out of 10 Malian urban dwellers live in Bamako. This situation presents two series of drawbacks: For overcapacity areas (Bamako). Young professionals seeking work practice, mostly for a transitional period, in relatively informal se ings (e.g., home consultations), while work for established professionals decreases. For subcapacity areas (regional cities). The public facilities are overwhelmed. Some patients could go to private facilities, but they are scarce. Thus, there is li le incentive to improve quality in existing public and private facilities. In addition, pharmacies do not bene t from specialty prescriptions wri en by private physicians who ll them. Moreover, the poor distribution of private medicine limits the absorption capacity of the market. To evaluate the maximum number of private practices and hospitals that can reach breakeven ( gure 4.2), average minimum activity levels to cover costs were assigned, CFA F 12 million a year for a private practice and CFA F 120 million a year for

Figure 4.2. Market Absorption Capacity for New Private Practices and Hospitals, 2009

AB The absorption capacity is stronger … than within Bamako District outside Bamako District… where market is close to saturation

Inside Bamako 250 250 Current number Current number 212 Absorption capacity Absorption capacity 200 200 194 175

150 150

100 100 75 49 49 50 50 50 21 0 0 Offices Private hospitals Offices Private hospitals

Sources: Part A, BCG analysis, 2009 data.; part B, DRH Ministry of Health, 2008 data; and BCG analysis. Note: Hypotheses: absorption capacity calculated through the ratio between potential turnover of o ces and private hospitals per region (average expenditure per urban inhabitant adjusted with a coe cient depending on the poverty area –0.6/0.8/1.3 x urban population of region) and the breakeven point of of- ces (CFA F 12 million of turnover per year) and private hospitals (CFA F 80 million of turnover per year). 28 World Bank Working Paper a private hospital. The market size for each region was then calculated from the urban population size and the average annual expenditure per urban individual. On this measure, Bamako appears to be close to saturation. The future growth of private providers therefore depends on improved geographical distribution.

Lack of Private-Public Cooperation Private providers are poorly connected with the public sector. This curbs their contribution to the achievement of public health objectives in health care, education, and disease prevention. Health care. In the absence of implementing texts for hospital law (n° 02-050 of July 22, 2002), there is no framework for private sector participation in public hospital service. Moreover, there is a lack of uidity in patient referrals between the public and private sectors, and there is no network for making the most of the skills and capacities available nationally and regionally. Education. Although private physicians are authorized to teach as temporary con- tractors, the private sector feels the teacher-selection criteria are opaque. In addition, private physicians are not authorized to supervise theses or to welcome graduates of the University of Medicine as interns in private hospitals and practices. Prevention. Although several private providers say they volunteer, CSREFs are reluctant to include private physicians in routine activities and vaccination campaigns. Indeed, public providers fear that requirements will not be ful lled (e.g., maintaining correct temperatures for vaccines, training vaccinators, maintaining a minimum volume of activity) and that the principle of free service will not be respected.

CATEGORIZATION OF HEALTH INSTITUTIONS The texts determining the categories of private medical and paramedical institutions have not been reviewed since 1991. Some directives no longer t the current context (due to growth in the private sector and technical progress in medical equipment and practices) and especially concerning the activities authorized and the necessary infrastructure in di erent types of private institution. Private medical practices regret that the current typology distinguishing permis- sible care at inpatient and outpatient institutions, respectively, does not allow them to render certain services without proving they have inpatient capabilities and some beds reserved for inpatient observation The situation is particularly muddled for authorization to perform obstetrical deliveries. Improving maternal and infant health is a priority objective, yet deliveries are authorized at the CSCOMs where personnel are often less quali ed than those at private facilities.

Start-Up Funding Private physicians have no mechanisms to support and fund their start-up, which costs an average of CFA F 8 million for practices and CFA F 20 million for private hospitals. Rarely do these physicians seek funding at banks, which are reluctant to nance such start-ups anyway. By default, most of these physicians self- nance or seek nancing from families and friends. This situation presents several disadvantages: Interest rates on loans from individuals are sometimes usurious. The relationship with those investors o ers li le legal security. Private Health Sector Assessment in Mali 29

Those investors do not demand the same proof of nancial viability (business plan) and compliance with quality criteria as banks. By not seeking bank nancing at start-up, a young physician forgoes an opportunity to establish a good credit reputation and trustful relationships for future funding needs. Private providers rarely report di culties meeting their funding needs after start-up. Their pro tability allows most of them to fund further development on their own.

START-UP SKILLS NOT TAUGHT AT MEDICAL SCHOOL To set up commercial facilities—during the rst two years—private physicians need certain skills not taught by the FMPOS in the areas of nance, accounting, taxation, human resource management, and information management. Neither does the FMPOS adequately prepare private physicians for practice in rural environments (e.g., clinical practice with limited technical platform, rural customs). These physicians need training in public health and management (accounting, taxation, human resource management).

Education

The education channel is characterized by weak instruments for regulating the number of health care professionals in initial training, inadequacy in the way this volume is set, and inadequate education for health professionals se ing up a private practice in a rural environment.

Need to Strengthen Strategies for Regulating Numbers in Initial Training For physicians and pharmacists, the numerus clausus established at the end of the rst year of training regulates the number of graduates. However, the creation of a private medical school could weaken the e ciency of this regulation system if the new school decides to increase the number of students (the numerus clausus, at this stage, is im- posed only on the FMPOS). For TSS/TS, there is no quota for the number of people certi ed. The National Education Institute for Health Sciences (INFSS) organizes an examination but not a competitive one. Law 94–032, Article 17, allows private schools to issue their own diploma (most of them, for the moment, refuse to do so). There is no mechanism for regulating the number of people preparing for examinations. This number is increasing with the opening of private schools and with the decrease in the quality of student preparation. Only the INFSS requires applicants to pass an admission examination. Nonetheless, more students pass the entrance exam than are graduated from the INFSS, and the nongraduated individuals feed a parallel market of less-quali ed job seekers.

Setting an Appropriate Annual Number of Trained Health Care Professionals An e cient mechanism for regulating the number of health professionals is indispensable. The market can absorb only so many new entrants a year, despite the often-heard complaints about a lack of human resources in the health sector. Only part of the population, mainly urban dwellers, has the nancial means to seek care in the private commercial sector. This potential market can generate enough revenues to cover the costs of only a limited number of practitioners. 30 World Bank Working Paper

Thus, with demand for private commercial health care constant, depending on demographic trends, the market will have a hard time absorbing the private practices and hospitals that the numerous physicians educated between 2000 and 2010 will want to open ( gure 4.3).

Figure 4.3. Market Absorption Capacity versus Young Physicians’ Hopes for Opening Private Practices and Hospitals

150 120

100 99 87 76 Offices 65 Private hospitals 53 50 41 28 14 15 6 0 1 0

Absorption capacity ratio -5 -10 -14 -16 -22 -28 -35 -41 -50 -48 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Sources: DRH Ministry of Health; AMLM; UTM; BCG analysis. Note: Absorption capacity is the ratio between the potential turnover of o ces and private hospitals (average expenditure per urban inhabitant x urban population) and the breakeven point of o ces (CFA F 12 million of turnover per year) and private hospitals (CFA F 80 million of turnover per year). Opening number calculated based on projected ows of medicine graduates (+3 percent from 2013) joining the private sector (50 hires in the civil service/year) and se ling in private establishments (80 percent with 2 physicians/o ce and 5 physicians private hospital).

The method for determining the number of students to be educated does not take into account market-absorption capacity. The FMPOS education capabilities (numerus clausus) are determined only by the school’s own supervisory capacity (premises, teaching personnel). The capacity to educate TSS/TS students is poorly regulated due to the absence of competitive examinations/numerus clausus.

Making Educational Quality and Adequacy Meet Health Care Professionals’ Needs The general quality of the initial education is de cient. For physicians and pharmacists. The market is saturated with FMPOS students. About 1,900 students are in the rst year of medical/pharmacy school but the market will be able to absorb only 800 graduates. There are about 4,200 students in medicine for 1,000 hospital beds in Bamako. For TSS/TS. Low-quality private schools are proliferating due to a lax regulatory framework (no criteria for checking the reality of supervisory capabilities and the soundness of the education provided). The adequacy of the educational content to prepare health care professionals for the new practicing conditions should be strengthened to be er take into account what they will need in private practice (e.g., management skills) and practice in rural areas (e.g., public health). Private Health Sector Assessment in Mali 31

Private Community Sector

An analysis of the community health situations leads to the following ndings: The average CSCOM depends on subsidies to cover its costs due to low sta productivity, low frequency of patient visits, and poor management capabilities of the ASACO. The CSCOMs are put into speci c situations according to their population pool and their contact rate, which should be taken into account. The success of strategies to expand rural services and trained medical sta depends on the support available for physicians se ling in a CSCOM. The CSCOM ecosystem is fragile. Major public health decisions should take into account the principle of cost recovery on which CSCOMs depend.

Portrait of an Average CSCOM Starting from a database of information sent by each CSREF to the central level, a picture of an average CSCOM can be drawn. They have Sta . Three agents upon opening Labor productivity. 500 consultations per employee per year Unit labor costs. CFA F 800,000 per year Fixed costs. CFA F 1,400,000 per year Variable costs. CFA F 150 per patient Revenue per patient. CFA F 1,000 (excluding drugs) Revenue per patient, pharmacy. CFA F 1,200 (15 percent of margin on drugs) Subsidies. CFA F 1 million of functioning subsidies—CFA F 1.6 million in the shape of two agents made available Contact rate. 0.23 per person per year. The average CSCOM runs a de cit due to labor-cost load (low agent productivity), and only subsidies allow it to reach the breakeven point ( gure 4.4).

Figure 4.4. Financial Balance of an Average CSCOM

12,000,000 80

10,000,000 60 8,000,000 Amount of the subsidy

CFAC 6,000,000 40

4,000,000

20 Number of CSCOMs 2,000,000

0 0 0 200 400 600 800 1,000 1,200 1,400 1,600 1,800 2,000 2,200 2,400 2,600 2,800 3,000 3,200 3,400 3,600 3,800 4,000 4,200 4,400 4,600 4,800 5,000 Number of curative consultations / year

Costs paid by the ASACO with subsidies Real costs without subsidy Revenues Frequency of CSCOMs

Sources: Bilan C les 2008 DNS CPS; interviews; BCG analysis. 32 World Bank Working Paper

Figure 4.4 shows Through the histograms, the distribution of CSCOMs by the number of curative consultations given (right-hand axis). The evolution of revenues (left-hand axis expressed in CFA F, hatched line) depends on the volume of activity, or on the number of patients going to the CSCOM, and on the average revenue per patient. The evolution of actual costs (solid line) is stable at the beginning ( xed costs) but increases each time the volume of activity entails the addition of one more agent— the actual costs (without subsidies) increase faster than revenues due to the low labor productivity. (The salary cost of an additional consultation costs a CSCOM more in salary than revenue generated by it, and breakeven is never reached.) The line representing evolution of the costs supported by the CSCOM (line with circles), or the costs it still must bear after factoring in subsidies, is much at- ter because it represents xed costs and the cost of consumables. Personnel are partly supported by the subsidies in the model. This dependence on subsidies weakens the principles on which community health relies. The contribution of subsidies is justi ed in certain proportions as compensation for the public service missions ful lled by the CSCOM and is included in the CSCOM’s business model (Decree of April 21, 1994, Article 25-2). However, when the CSCOM’s nancial balance is too heavily dependent on subsidies, they are harmful and under- mine community health care. The cost-recovery principle on which community health relies is weakened by funding that comes mainly from public sources. Moreover, some public funding is not sustainable in the long term (e.g., Heavily Indebted Poor Countries [HIPC] funding). Subsidies for personnel hinder ASACOs’ management authority, can disengage the personnel, and dissuade the patients when there is not enough activity to justify additional sta . The annual productivity of CSCOM personnel needs to be doubled to 1,000 consultations per agent to stabilize the total amount of subsidies and avoid increasing these subsidies when volume increases.

Strengthening ASACOs’ Managerial Capabilities ASACOs’ managerial capabilities are key in the mobilization of strategies to reestablish nancial balance through Cost decreases. Increase sta productivity, motivation and cohesion, organize work more e ciently. Revenue increases. Increase frequency of visits, inculcate a culture of quality, switch from a xed model to outsourcing some services, re ne health services available and pricing, raise the technical platform standard. These managerial capabilities are currently low: ASACO members are volunteers and not necessarily quali ed Continuous training/professionalization programs are poorly developed Resources dedicated by local state services to the support and advice function are limited, and this function is more focused on the concept of viability at the creation phase than the sustainability of operations long term In the absence of a bankruptcy or guardianship mechanism, there is no sanction for bad management Private Health Sector Assessment in Mali 33

Moreover, ASACOs’ managerial capabilities are weakened by the “o er policy” pursued by state and local authorities (while CSCOMs su er from slack demand), con- sisting of making personnel available. In other words, they o er too many services despite low demand. In addition, More than one agent out of two in the CSCOMs is not hired by the ASACO The managerial authority of the ASACOs and the center manager is hindered by the multiplicity of agents subject to di erent statutes and several hierarchical lines

Speci c Situations Five CSCOM categories would adequately re ect the highly varied intrinsic conditions within the centers ( gure 4.5): By nancial viability. Do they reach breakeven? In other words, does the minimum volume of activity cover their costs without subsidies and with a productivity of 1,500 contacts/agent/year? By population pool. The viability threshold is 5,000 inhabitants; the threshold to di erentiate urban and rural areas is 10,000 inhabitants.)

Figure 4.5. CSCOM Typology, by Catchment Area and Contact Rate

Financial balance line without subsidy, productivity 1,500, incompressible threshold 1.0

0.8 1% 16% Surplus rural CSCOMs Surplus urban 0.6 CSCOMs

Sub-critical CSCOMs 0.4 Contact rate 36%

Rural CSCOMs in deficit Urban CSCOMs 0.2 16% in deficit 31% 0.0 0 5,000 10,000 Population pool

Sources: Bilan C 2008 les DNS CPS; interview; BCG analysis.

Each of the ve CSCOM categories faces speci c issues, requiring adapted answers, especially in terms of pro le of subsidies provided: CSCOMs with too low a population (16 percent of the total). The catchment area is structurally insu cient to generate the required revenues. Created without meeting all the criteria for viability, those CSCOMs should adapt their business models to the area’s low population density and to the blocking factor of distance. Below the critical mass (minimal size to be economically viable), they should retain large subsidies. 34 World Bank Working Paper

Unsubsidized rural CSCOMs in de cit (36 percent of the total). Meeting all viability criteria, with low competition from modern providers, those CSCOMs (the ma- jority) can signi cantly reduce their dependence on subsidies. Under comparable conditions, similar CSCOMs with be er performance succeeded in consolidating their results. The subsidies provided to those CSCOMs should decrease over time and be allocated to improving treatment quality. Unsubsidized urban CSCOMs in de cit (31 percent of the total). Though situated in places where they could become nancially autonomous, those CSCOMs have not captured a su cient market share. Faced with strong competition, those CSCOMs should adapt their care to meet the competition and consumer pref- erences. Subsidies granted to those CSCOMs should be large enough to allow them to invest in technical platform improvements. Unsubsidized balanced urban CSCOMs (16 percent of the total). With activity and productivity levels that allow them to be close to pro tability, or nancial autonomy, they should continue to adapt to meet the competition and become centers of excellence for the other CSCOMs. Investment subsidies can be justi- ed to keep up the level of equipment. Unsubsidized balanced rural CSCOMs (1 percent of the total). They should maintain their situation, but they do not have the means to o er much support to the other CSCOMs. Subsidies for equipment maintenance should allow them to sustain service quality.

Expanding CSCOM Services and Trained Medical Staff The expansion of CSCOM services and trained medical sta allows reinforcement of ASACO/CSCOM managerial capabilities and improvement of their contact rate and revenues. At constant unit price, The cost/quality ratio of treatments improves with the expansion of services and trained medical sta . A physician can provide revenue-generating services (e.g., light surgery). The presence of a physician helps improve the technical platform and allows a more complete range of services to be o ered. Expansion of services and trained medical sta can promote the reputation of a CSCOM beyond its catchment area. The absence of an unequivocal statistical relationship between the presence of a physician and the number of visits can be explained by the fact that several conditions should be present for the proper integration of the physician within the ASACO/CSCOM: Preparation of physicians for rural practice A ractive nancial conditions and professional opportunities Quality of relationships with the ASACO Support and “socialization” of the rural physician.

Reconciliation of the Cost-Recovery Principle with the Public Health Programs A CSCOM’s ecosystem is fragile. Several conditions should be respected to avoid indi- rect damage to its nancial viability. Ensure compensation for any shortfall due to free delivery of some care and products decided by the authorities. Private Health Sector Assessment in Mali 35

Reconcile the centrality of the CSCOM in the health care network and the verti- cal programs to ght diseases/pandemics. Preserve the compatibility of (paying) activities of the CSCOM and of associative/religious providers within the catchment area.

Health Insurance

At the current pace of growth of private mutual insurance, less than 5 percent of the population will be covered in 2015 ( gure 4.6). With such a slow linear progression, a scale-up is thus necessary. The obstacles to scaling up have been clearly identi ed, and it should begin with preliminary experimentation in one or two pilot regions.

Figure 4.6. Health Insurance Coverage Rate, 2015

5 800 4.47% Beneficiaries 3.96% 4 Coverage rate CAGR 13% 3.50% 600 3.10% 3 2.74% 2.43% 2.15% 400 1.90% 701 2 1.70% 602 % of coverage 1.30% 1.30% 517 445 382 200 1 282 328 210 242 151 156 Number of beneficiaries in thousands 0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Sources: DNSI; Ministry of Social Development 2009. Note: Hypotheses: 13 percent CAGR in number of bene ciaries derived from the CAGR observed between 2005 and 2008 for existing mutual insurance plans; CAGR population of 3 percent.

One option for scaling up is the creation of 100 mutual insurance entities a year to meet the needs of the rural population at an a ordable price (CFA F 300 a month). The impact of such a deployment of mutual insurance would be highly signi cant for the health care system (increase of the CSCOM contact rate and activity volume). Finan- cially, rapid growth of mutual insurance coverage entails small adjustments for evolving needs during the di erent stages of growth.

Obstacles to the Expansion of Health Insurance There are ve main obstacles to the expansion of health insurance coverage: Social mobilization. Di culty convincing people of the relevance of a contingen- cy approach Contributive capacity and subscriber base. Required subscriber base to reach the equilibrium estimated at 3,000 bene ciaries; premiums to be mobilized in rural area of CFA F 3,000 per bene ciary; pre-harvest periods for rural populations whose revenues are seasonal Commercial model. Existence of a three-month waiting period while payment of premiums does not give right to the bene ts; absence of commercial incentives to subscribe to the system Quality and behavior of health care providers. Weakness of some CSCOMs; overbill- ing by private mutual insurance 36 World Bank Working Paper

Functioning and management. Coverage of management expenses beyond the technical balance motivation and training of mutual agents.

Scaling Up Requires a Preliminary Experimentation Phase An immediate scale-up, without experimentation, runs into two hurdles: (1) The Malian mutual insurance movement is too weak today to constitute a su cient starting base and (2) The modalities of an immediate scale-up in the Malian context are not su ciently described, and the body of best practices is not yet large enough to sustain an immediate scale-up. The administrative authorities and the UTM have insu cient experience to manage a much broader system; health care providers are ill-prepared for it; and the population has not been fully sensitized to its advantages. Moreover, the Ghanaian and Rwandan models are not directly transferrable, even though they demonstrate the posi- tive impact of a scale-up.12 The parameters of a deployment model rely on the creation of numerous private mutual insurance entities adapted to the rural population. To be er appreciate the conditions for scale-up success, a mutual insurance model was constructed With a subscription per bene ciary comparable to the one of the existing rural private mutual insurance rm: CFA F 300, and With a ractive reimbursement rates: 99 percent for CSCOMs, 75 percent for CSREFs, hospitalization in a hospital and pharmacy. A scheme to extend this mutual insurance model throughout the country was then elab- orated, moving from micro- to macroeconomic analysis: Seven years were posited to create a mutual insurance in each town in Mali. This scale of social mobilization is necessary so that as broad as possible an area of natural solidarity can be tapped. An a ractive penetration rate was set through a compulsory subscription scheme. Though not quite 100 percent, the rate is be er than under a voluntary subscription model ( gure 4.7).

Figure 4.7. Expansion of Health Insurance Coverage in a Compulsory Subscription Scenario

100 Adding populations taken in charge by AMO and RAMED, 58% of the population is 80 covered Mutual insurances AMO RAMED 60 58% 63% 65% 67% 67% 67% 67%67% 55% 60% 46% 40 37%

Coverage rate (%) 28% 20% 13% 7% 20 2% 16%

0 5% 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Source: BCG analysis. Note: Hypotheses: compulsory scenario—constant AMO and RAMED coverage rate. Private Health Sector Assessment in Mali 37

High Potential Impact on the Health Care System The systemic impact of the expansion of private mutual insurance was measured with emphasis on the expected bene ts for the CSCOMs ( gure 4.8). The results were By 2015, 37 percent of the population would be covered (in addition to the 25 percent covered by RAMED and AMO). The average contact rate would be double the rate under a business-as-usual scenario (0.29–0.57/persons/year) with a contact rate higher than 1 for the ben- e ciaries. CSCOM turnover of 80 percent would grow to 110 percent in 2015.

Figure 4.8. Impact of the Contact Rate on CSCOM Turnover

40 Turnover in the constant scenario Turnover in the voluntary scenario Turnover in the compulsory scenario 30 30 28 29 27 28 26 26 25 23 24 22 21 21 20 17 18 14

CFA F billion CFA 14 12 11 10 8 9 7 6 6 7 5 6 5 5 5 6 6 4 4 5 4 4 4 5 3 3 3 3 4 4 3 4 4 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Source: BCG analysis. Note: Hypotheses: Calculation for both scenarios of the increase in average contact rate as compared with the average contact rate in a constant scenario (CAGR of the contact rate in CSCOMs of 2 percent)— average revenue per patient in a CSCOM = CFA F 1,000 (outside drugs).

Controlling the Financial Impact through Simple Adjustments The nancial sustainability of private mutual insurance was measured at di erent stages of development: Technical balance (premiums less reimbursements) was maintained for about 10 years without adjustments to the initial scheme. Managerial costs put a strain on the total nancial balance from start-up, but minor adjustments (annual increase in the monthly premium of CFA F 20) enabled a systemic surplus ( gure 4.9).

Pharmaceuticals

The pharmaceutical channel is characterized by Uneven geographic distribution of pharmacies, which limits the market-absorption capacity Funding needs partly covered by pharmacies’ partners Insu cient preparation during initial education for needs while starting up a practice. 38 World Bank Working Paper

Figure 4.9. Compulsory Model with Constant Premium versus a Compulsory Model with Rising Premium

8 8 8 6 4 5 5 4 4 4 4 1 2 0 -1 0 -1 -1 -1 -1 -1 -1 -1 -1 -1 -4 -7 -12 -20 -20

CFA F billion CFA Overall result with increasing premium -29 Overall result keeping a fixed premium -40 -37 -44 -49 -60 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Source: BCG analysis. Note: Overall balance = total revenues – total costs (includes technical balance and management costs); key hypotheses: CFA F 20 increase of the monthly premium each year in the compulsory model with rising premium, constant subscription of CFA F 300/month for the model with constant premium.

Uneven Geographic Distribution and Absorption Capacity As a result of the current distribution of pharmacies and the zoning rules in force, there are waiting lists throughout Mali for new pharmacy licenses. This backlog will continue into the medium term. Assuming an average annual growth rate of 3 percent in the number of graduate pharmacists between 2013 and 2020), waiting lists will not begin to decrease until 2014 ( gure 4.10).

Figure 4.10. Backlog in New Pharmacy Licenses until 2014

400 Cost of support Number of rural physicians to be settled Hypotheses: 310 300 • Support unit cost: ~ CFA F 7 M / physician • Support of each of the 15% private physicians trained who become rural physicians 198 200

146 140 135 141 CFA F million CFA 124 129 112 109 114 119 100 43 27 19 15 15 16 16 17 18 19 19 20 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Sources: CDRH; FMPOS; CNOP; BCG analysis. Note: Hypotheses: 3 percent annual growth in the number of graduated pharmacists by 2013; 90 percent of the pharmacists in the private sector work in a pharmacy; 1 percent annual rate of growth in the number of pharmacists in the public sector. Private Health Sector Assessment in Mali 39

In the short term, the expansion of pharmacies in small cities is the main growth opportunity. For young pharmacists, se ling down outside big cities is the best remedy for the current lack of job opportunities. There are not enough other possibilities (e.g., development of diagnostic labs channel) to decrease waiting lists. A statute for the institution of an assistant pharmacist position is needed (and a law is being drafted) but it alone will not solve the long-term employment issue for most young pharmacists. For increases in business in the short term, wholesalers will have to expand their retail networks. Extension of the pharmacy network a ects the average pro tability of pharmacies that se le in less densely populated areas. In terms of revenues, since purchasing power in small cities is lower than in larger ones, the share of generics in their turnover (50 percent) is higher than the national average (30 percent).To maintain revenue ows, it is therefore important to o set the negative price e ect of the generic/specialty mix by volume increases and ensure that there are private physicians to guarantee a certain volume of specialties (prescriber). In terms of costs, the labor cost of salespeople is lower. Also, taxes are usually lower due to the low value of a store. Rents are also lower but this is o set by the cost of bringing the premises into compliance with norms in e ect. The supply cost is higher.

Start-up Funding Needs Partially Covered Pharmacists have two types of supporting mechanisms to fund their start up (needs estimated at CFA F 5 millions on average). The two main wholesalers, Laborex and Co- pharma, in the framework of a commercial agreement, fund the creation of certain pharmacies, especially by providing an initial inventory. For access to cheap loans, pharmacists negotiated a speci c partnership with Banque Atlantique. After start-up, pharmacies sometimes report funding di culties connected with the deterioration of their drug stock and with their working capital needs. Banking institutions and micro nance institutions partly cover those needs.

Training Needs during Start-Up Poorly Covered During the rst two years while pharmacists are taking their place as commercial providers, they need some skills and knowledge that their FMPOS education does not provide. This includes general information about how to start up a practice and speci c information on nancing, accounting, taxation, human resources management, and information management and systems.

Clinical Pathway

The opinion survey done for this study changes somewhat the common thinking about the role of traditional practitioners in Malians’ clinical pathway. Indeed, this role seems to have been generally overestimated (even after allowing for understatement by re- spondents): 3 percent for a rst consultation, 13 percent for the second. Those surprising 40 World Bank Working Paper numbers call into question the idea that traditional practitioners are frequently consulted at the beginning of the clinical pathway, before resort to conventional medicine. The decision to consult traditional practitioners is relatively revenue-inelastic up to CFA F 2 million but strongly decreases above that amount. The 58 percent average for a rst consultation at a CSCOM (81 percent in rural areas) con rms the powerful CSCOM role in the health care pyramid, and its crucial importance for rural populations, given the lack of an alternative in the eld of conventional medicine. About the other health care providers, the survey revealed that CSREF represents 8 percent of the providers chosen for rst consultation on average, (3 percent in rural areas) and 19 percent for second consultation. Hospitals account for 17 percent of the facilities visited on average (4 percent in rural areas), 23 percent for second visits, and 44 percent for third visits. Health care practice represent 3 percent of providers chosen for rst visits (0.5 percent in rural areas), 5 percent for second visits, and 17 percent for third visits. Private hospitals represent 7 percent of rst visit consultations (5 percent in rural areas), 17 percent of second visits, and 33 percent of third visits. The following are highlights from analysis of patients’ perception about those di erent providers.13 Patients believe prices and distances are appropriate for traditional practitioners and the CSCOM. Private hospitals and medical practices and, to a lesser extent, hospitals are perceived as o ering the best quality of service (cleanliness, equipment, sta skills, and quality of welcome and listening) The CSREF falls midway between the two extremes.

Governance

The governance of the health care system re ects the nature of the relationships between the administration and the private sector: Li le inclusion of the private sector in the de nition of health policies, which essentially rely on the contribution of the public providers (and, to a lesser extent, community providers) Li le inclusion of the private sector in the de nition of the regulatory environment that shapes it, given that the state, in its role of public authority, de nes private operators’ conduct (e.g., through rule making, enforcement, and tax collection). This governance mode does nothing to alleviate misunderstandings that have accumulated between the private and public sectors since the liberalization of 1985, thereby feeding grievances and distrust. This climate poses a major hurdle to the development of partnering relationships between the private and public sectors. It has to be recognized that some stakeholders refuse to engage in constructive dialogue, rst evidenced in the response of some private actors to their di culties making themselves heard. As a result, some health care professionals are gravitating toward the informal sector, and some physicians are emigrating. Some private schools are also thinking about issuing of their own diplomas. Private Health Sector Assessment in Mali 41

Beyond the improvement in this climate, a change in governance modes is crucial so that The private sector improves its understanding of the objectives and means of public health policy and contribute to it more e ectively. The state lls out its role as historic operator in the provision of care/pharmaceuticals by exercising a supporting and steering role for the private sector (stewardship).

5. Improving the Private Sector Contribution to Public Health Objectives

mong the opportunities identi ed for improvement, the strengthening of commu- Anity and rural health and the development of private mutual insurance are the most desirable targets for policy action. The systemic stakes are signi cant. Today, however, the public authorities and technical and nancial partners are probably not assigning su cient priority to those dimensions of the health system. The Boston Consulting Group models show that lack of demand is the main obstacle to expanding the base of the health pyramid—the CSCOMs—and that this demand can be fostered by creating risk-sharing mechanisms. Even if such ambitious policies require a large, sustained e ort from both authorities and donors, the primary care system cannot be strengthened without taking a close, fresh look at mutual insurance and the stakeholders in rural and community health. Mali has already proven innovative in this domain, but these experiments should be supported and expanded. Current policies focus on strengthening the availability of care, which, though necessary is not su cient under conditions of extreme poverty. Moreover, this policy, in the case of the CSCOMs, leads to a weakening of those private nonpro ts’ management capacity and threatens to inhibit their e orts to adapt health care to the local context, to motivate personnel, and to mobilize the population. In the same way, other components of the rural health care system do not receive su cient support despite the existence of innovative initiatives in civil society.

About Opportunities for Improvement

The methods sketched out in this section result from Primary analyses performed by BCG (modeling, opinion survey, etc.) Interviews conducted by various stakeholders Discussions during the rst two seminars. Some of these methods should be further analyzed and have not reached a su cient consensus at this stage. The others were validated by the Minister of Health during the March 15, 2010, seminar.

Strengthening the Public-Private Partnership and Dialogue

To reestablish trust between the public and private sectors and to clear the way for a partnering approach, it is necessary to 42 World Bank Working Paper

Create a dialogue and sharing mechanism between the public and private sectors. Include the private sector in the de nition of some of the goals of health policy so that programs can be crafted to help reach public health objectives. Have the private sector participate in the design and updating of the laws and directives that shape their work. Give the private sector incentives to become be er organized. For this, the following improvement levers have been identi ed: Creation of a public-private dialogue and consultation commi ee Creation of a transitional structure pre guring that commi ee Be er integration of the private commercial sector in the PRODESS Creation of a structure representing the whole private sector. A national policy should be de ned for reinforcement and implementation of public- private partnerships Strengthening the DESR (DNS) and creating a section dedicated to PPPs Creating agreement templates Sharing equipment and specialties in a given territory Participating in training activities Participating in examinations/diagnostic activities Participating in vaccination activities. Simply integrating the commercial components of the private sector in the PRODESS, though necessary, is not su cient. Even if this helps the private sector become more active in de ning the general lines of health policy and gives it incentives to become integrated with current organizations, the PRODESS does not address all the issues that make up the dialogue between the public and private sectors: The PRODESS addresses only PRODESS-related issues. Some questions, in particular about the revision of the regulation around the di erent channels (care, pharmaceuticals, and education) and the day-to-day enforcement of regulations are outside PRODESS jurisdiction. A complementary structure is thus required in order to a ain all the targeted objectives. That entity would have to have autonomy to examine and give its input on pending issues and would be closely aligned with the PRODESS.

Creation of an Interim Committee for Public-Private Dialogue and Consultation This interim commi ee, working with the public and private sectors, is intended to o er a forum for continuous dialogue within an institutional framework. Its role, still to be precisely de ned, could be To render opinions (optional or compulsory depending on the topic) on normative laws a ecting the private health sector To contribute to the enrichment of the strategic texts and documents related to public health To be a serious source of proposals and recommendations To steer the application of the joint public-private action plan that arose from the study of the private health sector in Mali, and to update it Private Health Sector Assessment in Mali 43

To this end, the commi ee could create specialized commissions for in-depth analysis of some topics and formulation of recommendations. To facilitate e ciency, this consultative group should meet the following to conditions: Representation. The commi ee should be made up of 12 to 14 members, with the same number from the public and private sectors. The membership should re- ect all interested parties (from the private sector, commercial, community, traditional, associative, and religious; from the public sector, ministries of health, social development, higher education, nance, and so forth). Chairmanship. To ensure balance and create a climate of trust, the chairmanship of this institution should be rotated to a representative from each sector in turn. Two key success factors have been identi ed: The establishment of a strong structuring of the private sector’s various components, the rst steps of which have been covered Good communication between this commi ee and the other consultative and steering groups of the Ministry of Health, in particular the PRODESS monitoring entities. To avoid delaying the formation of this commi ee while the private sector continues the structuring e orts initiated in early 2010, a transitional group can get started with the new commi ee’s work.

Integrate the Private Sector More Closely into the PRODESS The PRODESS monitoring groups at the national level (steering commi ee and technical commi ee) should open their membership to representatives of the private sector, who can then be be er exposed to the strategies and monitoring of the health care policy. While the associative sector is already connected through the GPSP, and the community sector through the FENASCOM, this association should be extended to the other components of the private sector: Commercial representation. To be determined. One possibility would be to o er a seat to the representatives of the three channels—care, drugs, education. Traditional representation. FEMATH. The revision now underway of Decree 01–115/PM-RM of February 27, 2001—about the creation of entities to direct, coordinate, and evaluate the health and social development program—o ers a chance to modify details on the composition of the monitoring and technical commi ees.

Reinforcement of the Organization of the Private Sector The creation of the public-private dialogue and consultation commi ee will give expo- sure to representatives of the private sector (in particular the commercial sector). Within the regrouping e ort, the creation of a transitional structure will be an additional incentive for the private sector to appoint interim representatives and to rationalize its current structure. 44 World Bank Working Paper

Reinforced Material and Communication Means Beyond the number and representation of the private sector’s spokespeople, the capacity of those associations/federations must be reinforced so they act as conveyors of their members’ concerns and disseminators of information to their members. This necessi- tates improvements in their means of communication (e.g., electronic newsle er, internal newspaper). The same observation applies to Professional Councils. Since contributions can be di cult to obtain, subsidies are recommended for the entities that will be appointed to represent the private sector within PRODESS entities and within the dialogue and consultation commi ee. This will support them in the ful llment of their role.

Implementation of a PPP to Foster Private Participation in Public Service Missions The de nition of a national policy is recommended for strengthening public-private partnership to a ord a consistent framework for each activity initiated and be er connect the various public and private components of the entire health system. Spelling out such a policy calls for close collaboration between the state and the private sector, through the dialogue and consultation commi ee. The creation of a framework to facilitate the development of PPP mechanisms also requires a strengthening of the DESR within the National Directorate of Health. The DESR is best placed, in association with the private sector, to propose PPP agreement templates. In any case, the development of complex PPPs for a growing number of health activities will require a long-term strengthening of public providers’ capabilities to steer complex contracts. This seems unlikely to happen in the short term without signi cant support and beyond some well-de ned pilot projects. A pragmatic option for the development of PPPs would consist of introducing a performance-based dimension to the subsidies granted to the CSCOMs (which can be analyzed as private entities in charge of delivering the basic health care package in a given catchment area in the framework of a PPP). As a prerequisite, the CSCOM environment should be taken into account, and the management capabilities of the contracting party, the ASACO, should be reinforced or at the very least, not weakened. Private institutions wishing to participate in public service missions, especially in public hospitals, should be authorized to do so by agreement with the public providers in order to de ne the modalities of this contribution and ensure observance of quality criteria. Four areas for public-private partnership have been identi ed: Through an agreement, authorize private hospitals to welcome FMPOS interns in order to increase opportunities for practical training, which are insu cient today. Authorize private physicians to supervise the training of medical students (under the same nancial conditions as public physicians). Create at the local level (health area or region) a scheme to share available equipment and specialties to avoid transferring patients to a higher level of the health care pyramid when there is a technical platform nearby. Through an agreement, associate private institutions that follow the prescribed procedures (cold chain, personnel training) with routine activities and national vaccination campaigns. Private institutions that do not have enough activity Private Health Sector Assessment in Mali 45

to reach critical mass by themselves will be able to be grouped under such a contractual regime. The ongoing revision of hospital law o ers a legislative vehicle for framing such PPP public service agreements.

Creation or Revision of Regulatory Texts

In any modi cation of the regulatory texts, the directives from UEMOA, West Afri- can Health Organisation (WAHO) of the Economic Community of West African States (ECOWAS) and WHO should be taken into account. It is important to di erentiate between the laws that need to be revised and laws on the books that are insu ciently enforced. Beyond the analysis of the required adjustments of these laws, the way they are perceived by the health sector must be taken into account. This perception can be biased or distorted by a misunderstanding of the laws, but it is still important to take it into account in the analysis because it determines the stakeholders’ trust in the system and, therefore, their behavior. The following ine ciencies in the regulation of the di erent segments (care, pharmaceuticals, and education) should be addressed: Conditions for authorization to open private health care schools that do not ensure supervision capabilities and teaching quality Conditions for granting wholesaler licenses, which, to date, allow more than half to do business without any state monitoring Issuing of health diplomas, which is not a state monopoly and risks creating several health professional markets Absence of zoning rules for physicians, of whom 70 percent are concentrated in Bamako.

Box 5.1. Wholesaler License Requirements

Decree 91–4318/Mspas-Pf-cab stipulates: “Article 18: Inventories of pharmaceuticals that wholesalers and their subsidiaries import or sell should be suf cient to ensure pharmacies’ monthly supply in the areas they serve. More- over, these inventories, in breadth, should encompass at least two thirds of the products that have obtained a marketing visa or authorization in Mali. “Article 19: All wholesalers and subsidiaries importing or selling pharmaceuticals should be able to deliver any product within that range to any pharmacy in their usual client base within 72 hours of receipt of the order.”

Another recommendation is to examine some conditions perceived to be too restrictive, which may curb the development of the private sector and limit its contribution to public health. For all those work streams, a plan and a timetable are necessary to make the approach credible and obtain quick results.

Relaxing the Categorization of Private Health Care Institutions The regulation for categorizing di erent types of private health care institution should be studied. Consideration should be given to relaxing the typology de ning health care 46 World Bank Working Paper establishments and hospitals, so that, for example, authorizing private practices to deliver babies or put their patients under observation. As one option, an intermediary cat- egory could be created to authorize those activities (exceptional overnight stays) without requiring full inpatient capabilities.

Tightening Wholesaler Licensing Requirements Criteria should be set to verify the activity of wholesalers applying for a license. Since current criteria are ill adapted, even for existing wholesalers with actual work, se ing a minimum turnover threshold is proposed to maintain the bene t of the license beyond start-up.

Tightening Training School Licensing Requirements The authority over training schools for health professionals should be transferred to, or shared with, the Ministry of Health. Requirements should be set for opening such schools—and licenses should not be renewed automatically without recerti cation of the promoters’ educational quali cations and supervisory capabilities. Among other requirements, schools should ensure the presence of a health care professional among its promoters, obtain a partner health provider’s agreement to accept its students for internships, and provide for the participation of specialists in some training. Any school that does not comply with these requirements by the end of a transition period should have its license revoked and should cease doing business. Further in-depth study should be devoted to the question of the school map and zoning of teaching institutions.

Af rmation of the State Monopoly on Diploma Awards in the Health Sector Law 94–032, Article 17, should be rea rmed to preserve the state’s regulatory monopoly over education in the health sector. Article 17 reads “Private educational institutions award diplomas that may or may not be recognized by the state.”

Zoning Rules for Physicians To limit the overconcentration of private physicians in Bamako, and to complement the measures to encourage them to set up practice in the interior of the country, study should begin for the elaboration of zoning rules for physicians along the lines of the establishment rules for pharmacies.

Procedure and Timetable for Revising the Laws To give teeth to the law modi cation procedure and get quick results, it is proposed that the dialogue and consultation commi ee appoint a commission to revise the laws governing the private sector. The commission, composed of representatives from the public and private sectors, should be tasked with drafting the necessary regulatory texts and laws. To guarantee legal consistency of the work, the commission secretariat should be provided by the Secretary General of the Government. The timetable is also important. It should Establish, in relation to the Parliament’s calendar, a schedule of laws to be revised. Set a deadline for modi cations of regulatory texts that do not require preliminary legislative reform (three or six months depending on the complexity of the ma er). Set a deadline for implementing the regulatory texts, counting from the day Parliament passes the modi cation of the law. Private Health Sector Assessment in Mali 47

Reinforcement of Law Enforcement Mechanisms

To improve compliance with the regulations, considering the general reluctance to sanction, self-regulation by reinforcing Professional Councils is proposed. The o ce of Om- budsman for the private sector should also be created, a proposal the stakeholders still have to study in depth.

Strengthening the Professional Councils’ Self-Regulatory Capacity The Professional Councils play a crucial role in the self-regulation of health care professions, complementing the state’s role of inspection and regulation. To strengthen that role, the Councils’ resources should be consolidated. One option would be to make a state agent available as permanent secretary or subsidize the operating budget of the Professional Councils to allow them to recruit such an agent. It is also necessary to start thinking about how the Councils can exercise their disciplinary roles more decisively in a cultural context that is inimical to the imposition of sanctions. Among the reform paths are: Modi cation of Article 41 of Law 86–35/86-AN-RM about the institution of the National Physician Council, which excludes public servants from the associations’ disciplinary power (and therefore puts a hint of bias on disciplinary commission decisions) Simpli cation of the disciplinary procedure, recognizing a defendant’s rights.

The Role of the Ombudsman for the Private Sector Insu cient consensus for implementation has been reached on the proposal to create the o ce of Ombudsman for the private sector. It should therefore be further examined and discussed along the lines of the following proposals.

ROLE AND OBJECTIVES The role of Ombudsman for the private sector (similar to the Ombudsman of the Re- public, created in 1997 in Mali, but with a much smaller eld of competence) is to facilitate fair enforcement of the laws in force. In a culture reluctant to impose sanctions, the introduction of an amicable recourse mechanism seems a way of strengthening fair enforcement of guarantees given the private sector. The objective is thus to improve relations between private professionals and the administration by examining instances of misadministration, for instance, misbehaviors and inadequate laws and procedures.

POWERS AND ATTRIBUTES The Ombudsman will seek amicable se lement of disputes between the administration and complainants and propose improvements in laws and procedures. The Ombuds- man is not a jurisdictional authority or an inspection corps, although he/she can refer disputes to such entities.

MODES TO REFER TO THE OMBUDSMAN A small team with its own budget would examine the admissibility of complaints. Health professionals could then take their complaint directly to the Ombudsman (creating regional delegates would be too expensive). 48 World Bank Working Paper

GUARANTEES OF INDEPENDENCE The Ombudsman will reports to the minister who appoints him/her, on recommendation by the dialogue and consultation commi ee. The ideal Ombudsman would be a professional respected by both the public and private sectors.

Strengthening Accreditation and Control Mechanisms In the context of the implementation of compulsory health insurance, use of quality accreditation mechanisms is an important means of persuading public and private providers to improve the quality of their services. The introduction of a payer is a proven, powerful incentive to improve health care quality. In the areas of national interdepartmental jurisdiction, it is important to reinforce coordination of the quality controls exercised by di erent ministerial departments over service and product quality. The authority over educational institutions is a particularly good case in point.

Strengthening the Education Policy

Health education is characterized by the ill-controlled proliferation of unquali ed and uncerti ed private providers and by the state’s di culty guaranteeing enough well- trained professionals to meet the system’s actual needs. The appointment in 2010 of a human resources director at the Ministry of Health will help the directorate move in this direction, improving the administration’s steering capabilities in this area. Strengthening education policy requires improvement in regulatory capacity by determining the number of personnel trained by public and private schools; preventing the development of an informal market in unquali ed health workers; increasing transparency in relations between public authorities and private stakeholders; improving educational quality for physicians, pharmacists, TSSs, and TSs; and making professional education more relevant to the conditions in which graduates will practice (private sector or rural environment). These endeavors should be integrated with e orts to harmonize education policies.

Strengthening the Tools for Regulating Education Education would bene t from several elements: the control of the size of the trained workforce, the prevention of the development of a parallel market for nongraduates, and the ability for the private sector to self-regulate.

CONTROLLING THE SIZE OF THE TRAINED WORKFORCE To regulate the number of physicians and pharmacists, the FMPOS’s numerus clausus will not be enough, if the rst private school of medicine opens. A legally binding agreement to limit education capacity should be negotiated with this school and any others that may later open. For TSSs/TSs, the current examination should be transformed into a competitive examination so that the annual number of paramedical graduates in each specialty can be speci ed in advance. As discussed above, the state should retain its monopoly over recognition of valid health care diplomas. As for siting and distribution of educational institutions throughout the country, consideration of school maps and zoning mechanisms should begin. Private Health Sector Assessment in Mali 49

PREVENTING THE DEVELOPMENT OF A PARALLEL MARKET IN NONGRADUATES To limit the disparity between the number of people preparing for examinations and the number of graduates (and the potential for a parallel market in health professionals) and to raise the caliber of students in health schools, an entry examination should be instituted and passing it made a condition for acceptance at private or public schools. Requirements for opening private health schools should also be tightened.

THE PRIVATE SECTOR’S RESPONSIBILITY IN SELF-REGULATION To verify that the supply of trained professionals coincides with the market’s absorption capacity, the private sector should be responsible for se ing the numerus clausus for physicians and pharmacists and for the number of spots opened to TSSs/TSs by competitive examination. Because private schools compete with the INFSS, they should be associated in the elaboration of the educational policy, in the se ing of the requirements for taking the entry examination for health care schools, and in the determination of the number of spots opened in TSS/TS competitive examinations.

Improving Training Quality The education of physicians, pharmacists, and health technicians should be improved.

EDUCATION OF PHYSICIANS AND PHARMACISTS The supervisory and welcoming skills of the FMPOS should be increased by involving the private sector in the education of physicians and pharmacists (internships in medicalized CSCOMs and private hospitals, and supervision of students by private physicians. The opening of FMPOS branches outside Bamako14 should also be encouraged.

EDUCATION OF TSSS/TSS Tightening the conditions under which private schools can be opened will help to rid the sector of bad schools. In addition, TSSs/TSs meeting the quality criteria should be supported by a preferential funding mechanism (discussed above).

Education and the New Practicing Conditions of Health Professionals A reinforcement of initial education modules preparing health care professionals for practice in the private sector and in a rural environment is desirable. Rural internships should be reintroduced in the FMPOS curriculum, and public health modules (e.g., in the form of a public health school project), and management training modules should be developed. Continuous training should be available during the start-up phase. The Professional Councils should organize training for members who switch to private practice. The program should include Training modules. Starting up a practice, nancing, accounting, taxation, human resource management, information systems Potential nancing. Public funding (FMPOS, Ministry of Health), professional associations, self- nancing, donors Potential trainers. Public (ANPE, etc.) and private operators selected by invitation to tender. 50 World Bank Working Paper

For rural physicians se ling in CSCOMs or as family doctors, training upon establishment is also necessary to encourage the success of programs to expand services and trained medical sta . This venture could draw on some of Mali’s recent experiences:15 Training modules. Rural medicine (clinical practice with limited technical platform, population’s habits), public health, management (accounting, taxation, human resources management) Potential trainers. NGOs and private training institutions selected by invitation to tender Complementary support. Tutoring, equipment kits.

Fight against the Illegal Pharmaceuticals Market

Reduction of illegal pharmaceutical tra c has to be a political decision: Obtain a commitment at the highest state level to overcome resistance to crack- downs and ensure a coordinated and determined push by all public services. Target the ght on counterfeit and dangerous pharmaceuticals and present it as such to the public. Intensify public awareness on the dangers of counterfeiting and involve in the campaign all public and private stakeholders in the health system. This e ort to repress a widely popular phenomenon would be easier if a concerted e ort were made to cut prices. The increased volume resulting from reduction of the illegal drug market would compensate reduced wholesaler and retailer margins. Further discussions with parties involved will be required. Another method would be to “integrate,” in part, the illegal drug market circuits into the o cial economy. Their competitive retail price advantage is indeed partially linked to their illicit access to smuggled and counterfeit merchandise. Tolerating their business while cracking down on the sale of counterfeit drugs would thus open a new way to respond to the phenomenon. The pharmacies’ refusal, rmly expressed, to acknowledge the illegal market in any way led to the deferral of this recommendation for the time being.

Implementation of Quality and Locational Incentives

The private for-pro t sector of the pharmaceutical and health care channels, and to a lesser extent education, are concentrated in Bamako. This limits their contribution to public health objectives and has negative consequences for the whole system (low-quality informal activities of young professionals who have di culties starting up, limitation of the absorption capacity of the market as a whole). In addition to focusing on ideas about zoning guidelines for physicians or favoring the development of continuous training programs for professionals who are just ge ing started, mobilization of economic incentive strategies is recommended to rebalance the geographic distribution of the commercial private sector: Through professional associations, disseminate knowledge of the tax breaks available to investors under the present tax regime. Create a mechanism to give new health professionals access to less-expensive bank funding through a partial guarantee.16 Private Health Sector Assessment in Mali 51

Introduce targeted tax exemptions to provide incentives for professionals se ling in the regions, within the framework of the Investment Code or as a complement to it.

Create an Information Center on Tax Breaks for Health Care Professionals The main tax break mechanism is the Investment Code. The one-stop shop of the Invest- ment Promotion Agency (API) acquaints eligible health professionals17 with tax breaks under the Investment Code (an investment under CFA F 150 million confers a ve-year tax holiday on pro ts and a three-year exemption on customs duties). However, this mechanism is li le known. Therefore, the professional associations should be tasked with informing their members about the tax relief available through an information center dedicated to this mission. The same center could also inform members of professional associations about the applicable scal regime, the refund procedure, and their rights as taxpayers. Relations between health professionals and the tax authority lack transparency.

Introduce a Mechanism for Preferential Access to Bank Funding In light of the disadvantages the scarcity of bank funding presents to health care professionals, and to support these professionals’ practices in the interior of the country, a mechanism should be created to give them preferential access to soft loans from banks. These loans would be characterized as follows: Amount of guarantee. Partial guarantee (50 percent) of a loan portfolio. (CFA F 1 billion represents about 50 percent of funding needs for new practices, private hospitals, and pharmacies in 2010–12 ( gures 5.1 and 5.2). Nature of guaranteed loans. Loans of more than one year to new providers (for the rst three years).

Figure 5.1. Estimated Annual Funding Needs to Start New Practices and Private Hospitals

1,500 Practices 1,254 Private hospitals Total

1,000 801

568 545 568 592

CFA F million CFA 523 480 501 500 453 440 460

0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Sources: Interviews; BCG analysis. Note: Hypotheses: Number of private hospitals and practices calculated without prejudice to the absorption capacity from the estimation of graduated in medicine (+3 percent from 2013) joining the private sector (50 recruitments in public sector/year) and joining private institutions (80 percent); two physicians/practice and ve physicians/private hospital—funding need per practice of CFA F 8 million and of CFA F 20 million per private hospital. 52 World Bank Working Paper

Figure 5.2. Estimated Annual Funding Needed to Start New Pharmacies

150

117 114 107 110 101 104 100 95 98 90 92 85 87 CFA F million CFA 50

0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Sources: Interviews; BCG analysis. Note: Hypotheses: Annual increase of the pharmacy numerus clausus for urban areas (potential number of pharmacies that can be opened) x average funding need per pharmacy of CFA F 5 million.

Bene ciaries. Practices, private hospitals, and pharmacies establishing in the interior (training schools could also become eligible in the future), maintaining quotas for di erent types of provider and avoiding favoring the best risks Maximum time for banks to bene t from the guarantee. The guarantee would be for three years, to encourage banks to behave proactively toward health care professionals. Propose a partnership with the banks in Mali. (Micro nance institutions might be interested in the smaller loans.) An alternative solution to lower the cost of credit, which can be accumulated with a guarantee, is to subsidize loans. Other nancial strategies, such as stock issues, could also be used.

Target Tax Exemptions for Health Professionals Locating in the Interior To encourage health professionals to se le in the interior of the country, revise the Invest- ment Code by introducing additional tax breaks for investments by health professionals locating in less-populated areas, extend the duration of tax exemptions, and set geographic eligibility criteria for the whole profession in order to rebalance demography. For pharmacists, either ensure their eligibility under the Investment Code or create a scal incentive through another legislative vehicle for establishing pharmacies in less-populated areas.

Bolster Rural Community Health by Consolidating ASACO and CSCOM Strengths

The nancial weakness of CSCOMs is often due to ine ciencies in ASACOs’ management. This situation is aggravated by a policy of making available personnel who are ill- equipped to deal with the problem of a below-breakeven number of visits to the centers. It is therefore proposed: Private Health Sector Assessment in Mali 53

To provide the ASACOs with external support in their management role To redirect subsidies toward actual CSCOM needs and according to their speci c situation To support programs to expand CSCOM services and trained medical sta .

Reinforcing ASACO Management Capabilities The prerequisite for strengthening ASACO management capabilities is to maintain management authority by ensuring that the support given matches their stated needs. Rais- ing awareness of these needs within state services, local communities, and NGOs is a necessity in that regard. Continuous training policies should be tailored and intensi ed to meet the speci c needs of ASACO members by making use of the services of external operators (e.g., NGOs) through agreements. Provision of external support is also proposed for ASACOs that feel they need to strengthen their managerial capacity: Managers would be selected by an invitation to apply from a group of ASACOs. The delegate would manage the CSCOM on behalf of the ASACO for the con- tractually speci ed time period and modalities. The delegate would work with the head of the CSCOM in an advisory capacity regarding strategic decisions. The delegate’s compensation could be partly indexed on results. The managers could be individuals, companies, NGOs, or even community development technicians. Potential cobackers are: the ASACOs, the FENASCOM, the state, NGOs, and the PTFs.

Redirection of the Subsidy Policy for CSCOMs CSCOMs su er from weak demand (low frequency of visits), but the policy pursued to date focuses on expanding care. To redirect this policy, it is recommended that the state and local authorities: Withdraw personnel made available for the CSCOMs if the center’s activity does not justify their presence. Redirect the support and advice provided to the CSCOMs toward auditing their nancial viability and justifying subsidies granted. Tailor the support provided the CSCOMs to their speci c situations (e.g., sub- critical CSCOMs, urban CSCOMs), favoring investment subsidies and moving gradually toward a general decrease in the amount of subsidies provided so that part of those amounts can be redeployed toward the development of private mutual insurance ( gure 5.3).

Support for Expansion of CSCOM Services and Trained Medical Staff A program should be established to support expansion of services and trained medical sta and to accelerate the se lement of physicians in the CSCOMs. It should be implemented through a tripartite agreement between the state, the FENASCOM, and any interested partner (selected by an invitation to tender). As a ballpark gure, an establishment-support program costs, per physician, about CFA F 7 million ( gure 5.4).The potential cobackers are the ASACOs, the FENASCOM, the state, NGOs, and the PTFs. 54 World Bank Working Paper

Figure 5.3. Ideal Growth Pro le for Different CSCOM Types

Sub-critical CSCOMs Average CSCOMs Urban CSCOMs

Growth profile Growth profile Growth profile Nr. of consultations Nr. of consultations Nr. of consultations

Time Time Time

Subsidy profile Subsidy profile Subsidy profile CFAF CFAF CFAF

Potential Development investments Potential investments

Functioning

Functioning Time Time Time

Source: BCG analysis.

Figure 5.4. Estimated Annual Funding to Establish Rural Physicians

146 140 135 141 CFA F million CFA 124 129 112 109 114 119 100 43 27 19 15 15 16 16 17 18 19 19 20 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Sources: Codija, Jabot, and Dubois 2009; interviews; BCG analysis. Note: The support includes: the study of the feasibility of the installation, training to CSCOM management for the physician and the members of the management commi ee, the physician’s equipment including the solar panel, the internship with a referent physician, and the contractual negotiation. Esti- mate of medicine graduate ows (+3 percent by 2013) joining the private sector (50 recruitments in public sector/year) and becoming rural physicians (15 percent).

Rural area programs to expand services and trained medical personnel, especially those to entice physicians to open private practices, should also be encouraged to ensure the consistency of health networks at the local level, especially between for-pro t providers and community institutions. Private Health Sector Assessment in Mali 55

Voluntary Expansion of Private Mutual Insurance

To support experimentation with a voluntary program to deploy private mutual insurance entities quickly, in preparation for scaling up, emphasis should be placed, with the support of the PTFs, on UTM activities to which a large part of mutual insurance management activities would be delegated Quick creation of new mutual insurance through an intensive social mobilization campaign Mutual insurance activities after their start-up (management costs, and so forth).

Test Quick Development of Private Mutual Insurance in One or Two Regions The analyses performed on the mutual insurance deployment model demonstrate the wide impact mutualist coverage can have on the health system. One of the possible options, which were thoroughly analyzed, is to begin with one or two regions where mutual insurance has a signi cant established base (e.g., Segou and Sikasso). There, an ambitious test could be conducted, guided by the strategy described in the model. Lessons drawn from two years of experimentation, would allow de nition of the modalities of a scale-up adapted to the Malian context. This can be done with support from the UTM, through social mobilization e orts and the creation of private mutual insurance entities, and successful operation of these entities after start-up.

Initial Scale-Up Support from the UTM Because of its experience and expertise, the UTM is in the best position to run a pilot program for scaling up mutual insurance ( gure 5.5). However, its current means are insu cient to support a signi cant increase in the number of mutual insurance and bene - ciaries. Subsidized strengthening of its means (personnel, IS) is therefore recommended. After this initial phase, the UTM will be able to cover its costs through fees paid by the newly created mutual insurance.

Figure 5.5. Private Mutual Insurance to Depend on Task Pooling with the UTM

Relations Structure Product Technical Sensitization Subscription Provision of with steering elaboration management and adherence collection care providers

Mutual insurances

UTM

Health providers

Mutual insurances focus on the Health care The total sub-contracting of technical functions to UTM allows subscription/retention of delivery stays professionalizing the management and reducing costs beneficiaries, subscription performed by collection, and the relationships NH-agreed Level of with the local health provider providers responsibility

Source: BCG analysis. 56 World Bank Working Paper

Support for Social Mobilization Activities and Quick Creation of Private Mutual Insurance Social mobilization is the rst bo leneck in the growth of mutual insurance. This activity requires A coordinated e ort among the mutualist movement, health care providers, state services, the local authorities, and the ASACOs The mobilization of specially trained teams able to deploy quickly at grassroots. Only an external operator (NGO), selected through an invitation to tender by the UTM and the state, is likely to ll out the insu cient workforce at UTM and within the social development services. The backer should support this initial mobilization e ort. Including the cost of training the mutual insurance manager, a mutual insurance start-up will a cost around CFA F 14 million the rst year ( gure 5.6).

Figure 5.6. Breakdown of Mutual Insurance Cost Items (percent of total costs)

Increase of health In % of total costs services provided 100 due to the increase of the frequency 80

Cost of health Starting cost: 60 CFA F 14 M per services mutual insurance Management/creation created 40 cost Cost of provisions 20 Cost of federative subscription 0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025

Source: BCG analysis. Note: The compulsory model was used here, but the pro le of the voluntary model is similar.

Post–Start-Up Support of Private Mutual Insurance The public authorities and the PTFs can also support mutual insurance activities after start- up by taking care of various adjustment needs. An analysis of existing mutual insurance shows the “best practices” for doing so. Two main types of subsidies are possible (table 5.1): Subsidize the technical balance. Operation subsidy, complement of subscription/bene ciary, assumption of part of the risks/populations Subsidize management costs. At federal level, at the level of each mutual insurance, reserve/reinsurance costs. In selecting from among these possibilities, pu ing an unsustainable burden on public nances should be avoided, and the autonomy and viability of mutual insurance should be preserved.

Clinical Pathway

In the clinical pathway, the addressable levers are related mostly to medium- and long- term measures to raise awareness and progressively modify cultural habits. People need Private Health Sector Assessment in Mali 57

Table 5.1. Adjustment Needs of Mutual Insurance over Their Lifecycle

Development stages Adjustment need at ISO-model Possible compensation methods Start-up CFA F 1.4 billion / year Subsidize the creation of mutual insurance Growth CFA F 4-18 billion / year Decrease management costs Subsidize some management costs Cover reinsurance expenses Increase premiums Raise copayments Renegotiate provider prices Maturity CFA F 3-30 billion / year Decrease management costs Subsidize some management costs Cover reinsurance expenses Increase premiums Raise copayments Renegotiate provider prices

Source: BCG analysis. to be made aware of the di erences between traditional and conventional medicine (using radio, traditional communication means, and so forth), and enforcement of the pro- hibition on advertising by traditional practitioners needs to be tightened. Action at the points of convergence between traditional and conventional sectors is also proposed by Training traditional practitioners to make use of conventional health providers Training conventional physicians to be able to refer to traditional practitioners. Finally, it is important to support the structuring of traditional practitioners (capacity to regroup and dialogue as a single actor with partners and regulator), especially by integrating a referent within the DNS in charge of easing the interface between the profession and the authorities, as a complement to the role played by the INRSP in the research eld.

6. Operational Proposal for Governance

he elements described below are a rough outline of a governance structure that Tre ects seminar participants’ recommendations concerning the public-private dialogue and consultation commi ee, the public-private partnerships entity, and the technical adviser for the private sector. The proposals for the creation of a dialogue and consultation commi ee were not endorsed as such are presented here as suggestions.

Public-Private Dialogue and Consultation Committee

The public-private dialogue and consultation commi ee will be cochaired by a representative of the state and a representative of the private sector. It will consist of 15 representatives of the private and public sectors: Ministry of Health: ve members (DNS, DPM, DAF, Inspection, CPS) Ministry of Higher Education: one member Ministry of Social Development: one member 58 World Bank Working Paper

Secretariat General of the Government: one member Private sector: seven members (the objective is to represent the for-pro t and nonpro t private sectors and all the channels: education, care, health insurance, drugs. The representatives will be appointed for four years. The commi ee’s secretariat will be a technical adviser from the Ministry of Health (e.g., the adviser to the minister for the private sector). The public-private dialogue and consultation commi ee will write an annual report on its activities. The report will be sent to the minister and its cabinet members by the technical adviser for the private sector (reporting to the Secretary General) The public-private dialogue and consultation commi ee will meet every two months. On occasion, it can be summoned upon request by one third of its members and should meet within 10 days. The commi ee’s role is to ensure follow-up of the implementation of the action plan resulting from the study of the private sector and to update this document. In addition, it will examine any other topic related to relations between the public and private sectors that members wish to include in the agenda (through the secretariat). The commi ee can create thematic, ad hoc commissions and will monitor their work. The thematic commissions should present their conclusions within six months to ensure a short examination cycle. As an illustration, the following commissions have been proposed for the study of key issues in the strengthening public-private partnership ( gure 6.1):

Figure 6.1. Proposed Organization of the Public-Private Dialogue and Consultation Committee

Other Minister of Health Activity report Ministries once a year General Technical Advisor Secretary Higher education Personalized Services services affiliated to GS Social Committee for consultation and public / private dialogue development National Direction of Administrative direction pharmacy and financial Health of health and drugs direction inspection Representatives of the public sector 7 Public / private (4 Min. health Representatives partnerships + 1 Higher of the private entity education + 1 Social Dev.) sector 1 government general secretary

Ad-hoc commissions

Source: Seminar participants recommendations, BCG analysis. Note: Simpli ed representation; DRH integration conditioned by its functionalization; Personalized services includes EPA, EPHs, EPICS, EPST, and state companies; services a liated to the General Secretary include CPS, CEPRIS, CNIECS, PNLP and CADD-MS. Private Health Sector Assessment in Mali 59

Commission for private sector support. Encompasses (beyond the members of the full commi ee) the PTFs, the associations, the API, the Ministry of Finance, the Ministry of Economy, representatives from micro-credit and banking institutions. Addresses topics about access to funding and the scal regime. Commission for the education of health personnel. Encompasses (in addition to the members of the full commi ee) representatives from the Ministry of Higher Ed- ucation, the Ministry of Health, public and private public health care providers, and training schools. Addresses the following topics: association of the private medical school with the FMPOS numerus clausus, creation of a competitive examination for TSSs/TSs, creation of an entry examination before enrolment in training schools, modalities to associate the private sector with the organization of competitive and noncompetitive examinations, and to the se ing of the numerus clausus and the spots open to the competitive examination for TSSs/TSs. Commission for the categorization of health institutions. Encompasses (beyond the members of the full commi ee) all the professional associations. Proposes an evolution of the laws about health care institution categories.

Public-Private Partnerships Entity

The Public-Private Partnerships entity, which could be hosted within the DNS Division of Health Equipment and Regulation (DESR), will be in charge of supporting of the formation of partnerships between public and private entities. It will tap its expertise to: Propose template contracts to the various parties, according to the desired objectives. De ne the required means for monitoring those contracts for the public authority. It will play a key role in the design of PPPs: Sharing of equipment and specialties at the health area Private sector participation in vaccination activities Private sector participation in educational activities Support for the expansion of services and trained medical sta of the CSCOMs (state/FENASCOM/NGO agreement) Intensi cation of social mobilization programs around private mutual insurance.

Entrust Questions Related to the Private Sector to a Technical Adviser

It is essential to anchor the questions related to the private sector and the formation of the proposed action plan as close as possible to: The point of decision and political impulsion The Secretary General’s coordination and operational level. Entrusting a technical adviser of the Minister/Secretary General with following those issues is consequently proposed. That adviser, chosen by the Minister/Secretary General, would run the secretariat of the public-private dialogue and consultation commi ee. It is important that all stakeholders, especially those from the private sector who are less familiar with the split roles within the owchart of the Ministry of Health, can easily identify that technical adviser as their point of contact within the cabinet. 60 World Bank Working Paper

7. Joint Public-Private Action Plan

An action plan was validated by the participants from the private sector and the Min- istry of Health at the March 15, 2010, seminar held in Bamako in the presence of HE Oumar Ibrahima Touré, Mali’s Minster of Health. This action plan encompasses the major challenges faced by the Malian health sector analyzed through a systemic approach, and covers the following objectives (table 7.1): Strengthening the public-private partnership and dialogue Creation and revision of regulations and reinforcement of enforcement mechanisms Reinforcement of the education policy Fighting against the illegal market in pharmaceuticals O ering incentives to improve quality and distribution in the private sector Consolidation of rural and community health care Voluntary extension of private mutual insurance. Levers mentioned in that action plan show di erent levels of technical maturity and political acceptance, which is fully recognized in their status (to be implanted versus to be further discussed). Among the most prominent orientations set on that occasion, the following ones should be highlighted: Creation of a public-private dialogue and consultation commi ee and, consequently, creation of a structure representing the whole private sector Revision of requirements for authorization of training schools and drug wholesalers Con rmation of state monopoly on the delivery of health care diplomas Encouragement of sharing of public and private school means Expansion of training capacities for physicians and pharmacists by associating the private sector Creation of speci c centers within associations and unions to improve knowledge of tax laws and current tax breaks Improvement of access to funding for new professionals through partial guarantee of bank funding and other nancial strategies Introducing tax incentives targeting establishment in regions within the framework of or complementary to the Investment Code Reinforcement of ASACO and CSCOM management capacities through support of continuous training programs and of governance e orts and contribution from an external support Initial support to UTM scale-up to accompany extension of coverage Support to social mobilization activities and subsidization of quick creation of mutual insurance Private Health Sector Assessment in Mali 61

Perspectives for Further Investigation

Some strategies have been identi ed for further complementary discussions: Creation of an Ombudsman for the private sector to improve law enforcement and to o er the private sector a nonjurisdictional recourse mechanism in cases of misadministration Beginning discussions about zoning rules for physicians in the private commercial sector Obtaining a political commitment at the highest level about the ght against the illegal pharmaceutical market in exchange for a devised agreement about accessibility to drugs and health care Redirection of current subsidies to satisfy the actual needs of CSCOMs in their particular situations. Besides the continuation of the restructuring e ort initiated by the private sector, the formation of a transitional structure pre guring the public-private dialogue and consultation commi ee is a priority for further investigation. This strategy, validated by all the stakeholders, will facilitate or even be a prerequisite for the implementation of numerous other improvement axes. Finally, from a statistical viewpoint, the available data provide numerous lessons but seem insu ciently exploited. From this viewpoint, it seems particularly appropriate for the Malian authorities: To consolidate available demographic data by reconciling the lists of the members of professional associations (inventory of active physicians and pharmacists) and the data from the FMPOS about the ow of graduates since the creation of the Medical University. Once those elements have been reconciled, specifying the number of health care professionals in Mali will be easier. Today, these numbers are estimated almost exclusively from public service data. To monitor more precisely the evolution of the CSCOMs, which so far has been estimated mainly through activity volume and the technical platform (on the basis of initial viability criteria). Today, the Bilan C les from the CSREFs are evidently underexploited by the Ministry of Health and the FENASCOM. After substantial cleaning and partial revision of the architecture, those les are a good basis for analysis and monitoring of a di erentiated policy to support the CSCOMs. Such a policy would allow separation of the CSCOMs by their basic characteristics (catchment area, etc.) and their nancial situation. There are also some statistical blank areas. Generally, data about the private sector are few, due especially to private stakeholders’ reluctance to give the authorities information. Information on the education sector is especially thin. The operation of the DRH should close that gap. 62 World Bank Working Paper

Table 7.1. Joint Public-Private Action Plan

Item Activities Actions Pilot Validation Deadlines Strengthening the public-private partnership and dialogue 1 Create a public- • Law creating the public-private CPS and Initiate September private dialogue dialogue and consultation private sector implementation 2010 and consultation committee committee • Appointment of administration and private sector representatives 2 Create a transition • Joint de nition of the modus CPS and Initiate March– structure pre guring operandi of the dialogue private sector implementation September the dialogue committee 2010 committee • Appointment of temporary representatives by the private sector and the administration 3 Improve integration • Revision of Decree 01–115, SG of the Initiate Second of the commercial setting the composition of Ministry of implementation semester, 2010 private sector into the PRODESS monitoring entities Health PRODESS 4 Create a structure • Finalization of discussions within Private sector Initiate June 2010 representing the the private sector about its implementation whole private sector ef cient structuring and vote on the statutes of the recognized structure • Estimate of the required means (human and nancial), especially for communication between its components in Bamako and in the regions • Financing 5 De ne national policy • Initiation of discussions within SG of the Initiate First semester, to reinforce public- the dialogue committee and its Ministry of implementation 2011 private partnership pre guration structure about a Health political document project Reinforcement of the partnership and dialogue between the public and private sectors (continued) 6 Implement public- • Reorganization of the DESR DESR (DNS) Initiate private partnerships: to bring it closer to the private implementation reinforce the DESR sector (DNS) and create a section dedicated to the PPP 7 Implement public- • Preparation of template DESR (DNS) Initiate private partnerships: contracts implementation Create template PPP • Adoption of the regulations agreements possibly required Sharing of equipment and specialties in a given territory Participation in educational activities Participation in examinations and labs Participation in vaccination activities Private Health Sector Assessment in Mali 63

Table 7.1 (continued) Item Activities Actions Pilot Validation Deadlines Creation or revision of regulations and reinforcement of enforcement mechanisms 8 Revise • Modi cation of the laws and Ministry of Initiate First quarter, requirements for introduction of transition period Health and implementation 2011 authorization of • Reinforcement of coordination Ministry of training schools mechanisms between the ministries Education of health and education 9 Revise requirements • Modi cation of the laws and DPM and IS Initiate March– for authorization of introduction of transition period implementation September drug wholesalers 2010 10 Consider strengthening • Joint setting of quality criteria DNPSS, DNS Initiate March 2010– AMO accreditation to be followed by public-private implementation June 2011 and quality institutions agreed to by the AMO 11 Strengthen self- • Revision of the laws regulating Professional Initiate September regulation capacities sanction powers of associations and Councils implementation 2010 of professional internal regulations associations • Identi cation of means required to reinforce the association’s administrative and communication means • Financing 12 Create an • Discussion to be continued in the SG of the Discussion to First quarter, Ombudsman for the framework of dialogue committee Ministry of be continued 2011 private sector Health Reinforcement of the education policy 13 Strengthen • Preparation of an agreement Ministry of Discussions to 6 to 12 months strategies to set associating the private medical Health, Ministry be continued quotas for trained school with the numerus clausus of Education, on ways and workforce and and initiation of negotiations and INFSS means re ection about • Initiation of re ection on creation of zoning competitive examinations for state TSSs / TSs • Initiation of re ection on creation of an entry examination for enrolment in training schools 14 Con rm state • Modi cation of Article 17, Law DRH Ministry Initiate 6 to 12 months monopoly on the 94–032 about the status of private of Health and implementation delivery of health education Ministry of diplomas Education 15 Encourage sharing • De nition of needs and available Association of Initiate 6 to 12 months of private and public resources private schools implementation school means • Preparation of a template sharing agreement 16 Expand training • De nition of the contribution the Ministry of Initiate the 6 to 12 months capacities for private sector could give Health and implementation physicians and • Preparation of a template Ministry of pharmacists by agreement Education associating the private sector 17 Ascertain adequacy • Listing of precise needs of health DRH Ministry Initiate 6 to 12 months of training for new professionals of Health implementation practice conditions • Evolution of FMPOS educational of health care programs professionals • De nition of objectives and identi cation of support needed by the associations to organize continuous training • Identi cation and search for required funding 64 World Bank Working Paper

Table 7.1 (continued)

Item Activities Actions Pilot Validation Deadlines Fight against illegal market in pharmaceuticals 18 Obtain a political • Explaining the issue at the levels SG of the Discussion to be 12 to 24 commitment at of Prime Minister and Presidency Ministry of continued months the highest level of the Republic Health in exchange for a negotiated agreement about the accessibility to drugs and health care 19 Intensify awareness • Evaluation of the ef ciency of CNIECS Initiate the 12 to 24 campaigns about previous campaigns implementation months the danger of • Association of the whole counterfeiting, and profession to the de nition of a associate all heath new campaign care public and private players Incentives to improve quality and distribution in the private sector 20 Create a speci c • Identi cation of a resource person Association / Initiate 12 to 24 center within within each association and union Union (to be implementation months associations and • Preparation of information determined) unions to improve documents knowledge of tax laws and current tax breaks 21 Improve access • Detailed analysis of needs Association Initiate 12 to 24 to funding for new and modalities of considered and implementation months professionals mechanisms professional Partial guarantee of • Initiation of discussions with union bank funding banking institutions Other nancial • Implementation strategies (participations, etc.) 22 Introduce tax • Analysis of existing mechanisms DNS and API Initiate the 6 to 12 incentives targeting and the eligibility of the different implementation months establishment in health channels regions within the • Preparation of laws revising the framework of or Investment Code or of ad hoc complementary to the laws for ineligible health channels Investment Code 23 Begin discussions • Continuation of analyses Association Discussion to be 6 to 12 about zoning rules for of demographic trends and continued months private physicians absorption capacities • Exploration of possible zoning mechanisms Consolidation of rural and community health care 24 Reinforce ASACO and • De nition of the objectives and FENASCOM Initiate 6 to 12 CSCOM management identi cation of support needs for implementation months capacities the ASACOs Support of continuous • Identi cation and search for training programs and required funding of governance efforts • Preparation and launch of the Contribution from an invitation to tender external support • Planning and deployment

Private Health Sector Assessment in Mali 65

Table 7.1 (continued)

Item Activities Actions Pilot Validation Deadlines Consolidation of rural and community health care (continued) 25 Redirect subsidies • Preparation of an assessment of Ministry of Discussion to 12 months toward actual needs subsidies granted in each health Health and be continued of CSCOMs and care area MATCL according to their • Preparation of best practices for speci c situations state, local authorities, and NGOs Progressively • Redeployment of the personnel withdraw personnel available whose presence is not justi ed by CSCOM level of activity Redirect the state support and advice toward the audit of nancial sustainability Tailor support to CSCOMs according to their speci c situations 26 Develop medical care • De nition of the objectives and AMC / Santé Initiate 6 to 12 in rural areas identi cation of support needs Sud and implementation months Estimate of impact • Identi cation and search for FENASCOM and sustainability of required funding support programs • Preparation and launch of the to rural health care invitation to tender networks and the • Planning and deployment medicalization of CSCOMs Voluntary extension of private mutual insurance 27 Give initial support • De nition of the objectives and SG of the Initiate 12 to 24 to UTM scale-up to identi cation of support needs Ministry implementation months accompany extension • Identi cation and search for of Social of coverage required funding Development 28 Support social • De nition of the objectives and SG of the Initiate the 12 to 24 mobilization activities identi cation of support needs Ministry implementation months and subsidization • Identi cation and search for of Social of quick creation of required funding Development mutual insurance • Preparation and launch of the invitation to tender • Training of social mobilization teams • Planning and deployment 29 Study, based on • Analysis of lessons to be drawn SG of the Initiate 3 to 6 existing mutual from existing private mutual Ministry implementation months insurance entities, insurance of Social the best means • De nition of the objectives Development to supporting new and identi cation of support mutual insurance needs (e.g., technical balance, management)

Source: Seminar, BCG, March 15, 2010. Note: This plan was validated at the March 15, 2010, seminar in Bamako by the private sector participants and the Ministry of Health. 66 World Bank Working Paper

Notes

1. Administrative division grouping in principle 5,000 to 10,000 inhabitants within a 15-km radius. 2. Analysis of main components is based on the survey of populations’ health care behavior and on the averages obtained by each provider for each criterion (excluding the itinerant healers, projected on components 1 and 3). 3. CFA F 300,000 for foreign students (source: interviews with FMPOS deanship). 4. State midwives, state nurses, pharmacy laboratory technicians, decontamination technicians. 5. Obstetrician nurses, public health technicians, laboratory and pharmacy technicians. 6. In other words, one consultation per illness episode with a hypothesis of a 120 percent mortality rate. 7. This rate is likely understated in the survey results. 8. The creation of a Professional Council of Nurses and a Professional Council of Surgeons is being studied. 9. Representing the profession more than players in the private sector. 10. Despite this free-price regime, wholesalers and retailers set their margins by consensus. 11. Estimates based on data collected from a panel of public and private health care professionals. 12. Consultation rate of mutual insurance bene ciaries in Ghana (2006) is four times higher than average. In Rwanda, mutual bene ciaries had access to conventional health care services at a rate twice as high as nonbene ciaries (2005). 13. Analysis in main components about the evaluation dimensions of the various providers. 14. This will indirectly help to improve the quali cations of personnel in the regions. 15. Santé Sud NGO in partnership with the Association of Rural Physicians. 16. Initial discussions on this topic took place with Bank of Africa, which expressed its interest in principle in participating in a mechanism of this type. 17. The eligibility of pharmacists is questionable because they can be compared with shopkeepers. Appendixes

A. Methodology and Main Findings B. Project Approach C. Terms of Reference of the Steering Commi ee D. Malian Household Survey Questionnaire on Health-Seeking Behavior E. Sampling Method for the Malian Household Survey of Health-Seeking Behavior F. Institutions and Personalities Associated with the Work on Stakeholder Engagement

Appendix A. Methodology and Main Findings

Primary Data and Modeling

Pre-existing primary data collected during the project are of four types: Demographic data. Number of medical school graduates since its creation, council directories, Ministry of Health data on distribution of its workforce by profession Data related to community health centers (CSCOMs). “Bilan C” les consolidated by the Health Planning and Statistics Unit (CPS) and lled in by the(Reference Health Center (CSREF) 2nd level) based on a survey of community health associations (ASACOs) Data related to private mutual insurance. Key gures on the mutual insurance movement established by the Ministry of Social Development and data from the Technical Union of the Malian Mutual Insurance System (UTM ) on the ben- e ts package proposed within the framework of its voluntary health insurance (AMV). Macroeconomic studies. Health demographic studies and national health accounts The quality of those data varies. All the databases were cleaned and consolidated: Demographic data. There is li le data about the total number of physicians (and other health professionals) practicing in Mali, and blanks on the private sector are especially large. Professional association directories are incomplete and do not provide a clear picture of their geographic distribution. The method selected involved reconstituting the data about the number of active private physicians and pharmacists educated at the Medical Faculty and projecting their distribution throughout the country on the basis of hypotheses derived from the public provider distribution. Those data allow an estimate of the number of private health providers in the di erent regions, starting from hypotheses on the average number of professionals working in private practices and hospitals. The robustness of those elements was then tested through observations in the eld and interviews with professionals. Data on CSCOMs. The methodology used is based largely on the nancial modeling of an average CSCOM and the simulation of the macroeconomic e ects of policies supporting those providers, in particular contact rates. Data stemming from Bilan C les were cleaned (incomplete les and les with evident computing mistakes or discrepancies were eliminated). These data were consolidated into a base encompassing all the elements directly useful for building a model. A typical CSCOM pro le was deduced from that database (amount of subsidies received, active personnel, contact rates, and so on), as well as a typology of the various types of CSCOM. Those elements, especially the nancial ones, were compared with the actual pro t-and-loss accounts of a sample of CSCOMs—especially to determine the average revenues and costs of a CSCOM. These data were re ned during eld visits. Correlation calculations were also made on that basis to determine the link between registered nancial and health results and

69 70 World Bank Working Paper

the di erent types of support provided (impact of the expansion of services and trained medical sta , the provision of unquali ed personnel, and so on). Data on private mutual insurance. Data on the mutual insurance movement as a whole from the Ministry of Social Development are relatively robust and were not subject to speci c reprocessing work. Construction of the development model of rural mutual insurance used, as a microeconomic base, the voluntary health insurance (AMV) product proposed by the UTM (but with slight revi- sions in the bene ts package and a slight decrease in the cost of the insurance to meet the rural clients’ expectations). Previous UTM estimates of start-up and operating costs for rural mutual insurance allowed the nancial balance of such a product to be modeled during its expansion phase. Data also existed on the impact of enrolment in a mutual insurance on bene ciaries’ health-seeking behavior (contact rate). Macroeconomic studies. Because available studies used di erent methodologies, signi cant consolidation was necessary to reconcile the bulk of health funding in Mali. Those data were triangulated with the estimated turnover of private and public health providers, starting with contact rates by provider (data available for part of the public providers and reconstituted from the average number of consultations per day for private providers) and the average price of various services. In the special case of medicines, total revenue was calculated from data provided by the main wholesalers and the margins applied along the whole value chain. The gap between pharmacies’ revenues and estimated expenditures on medicines allowed the volume of the illegal drug market to be estimated.

Opinion Survey: Malians’ Health Behavior

To ll in blanks in the available documentation, BCG commissioned an opinion survey, conducted by the RESADE research rm. This survey included 1,050 households. It was made up of a sample composed of three regional capitals and the Bamako District, eight areas, and 40 towns. (see appendix E for technical details). The objective was To measure Malians’ clinical pathway as a way of be er understanding refusal to receive health care, the amount of time before soliciting health care services, and the respective roles of traditional medicine and public and private providers. To understand who, in Malian households and along this path, decides to use, and pay for, health care. To measure the cost and the waiting time for each provider. To evaluate criteria used in the choice of one provider over another: trust, proximity, cost, and expertise. To rank di erent providers according to patients’ evaluation of the services: ef- ciency, distance, price, medicine availability, competence, quality of welcome and listening, cleanliness, and equipment quality. This study concluded: The rate seeking “external support” is 42 percent (41 percent consulting conventional providers, a hypothetical 1 percent consulting traditional practitioners). The rate of forgoing health care is 63 percent. Private Health Sector Assessment in Mali 71

The rate of self-medication is 15 percent (8 percent choosing traditional herbs, 7 percent choosing modern medicines). In 90 percent of the cases, the decision to seek health care is made by the head of the family or a member of the family. The most important criteria for choosing the provider are e ciency of recovery, competence of the personnel, and their quality of welcoming and listening. On all criteria assessed, CSCOMs and CSREFs are the best-valued providers. Several other elements highlighted by this survey are included in the body of this report.

Additional Elements on Data and Sources

This report di erentiates two types of observations about the current situation: The objective elements of diagnosis (based on facts and quanti ed); The subjective feelings and impressions expressed. When those feelings direct behavior, they have, or can have, an important impact on the health system. The methods for compiling the objective data used by BCG were validated by the steering commi ee during di erent meetings. Depending on the case, the methods included: Gathering primary data (for example, opinion survey about clinical pathways) Exploiting existing or recomposed databases (for example, analyses done on CSCOMs) Constructing economic models from hypotheses validated with the participants and against existing factual elements (for example, scenarios constructed about CSCOMs and mutual insurance) Collecting (in the absence of other methods) data from a panel of health professionals (for example, average time to obtain an agreement/license) The ndings summarized in this report were shared in Bamako with more than 60 stakeholders during seminars on August 13–14, 2009; October 26–28, 2009; and March 15, 2010; at regular meetings of the project steering commi ee and at the meeting of the extended cabinet on November 16, 2009. In addition to those o cial meetings, during the project the BCG team had numerous informal interactions (more than 100 interviews) with the players in the Malian health system.

Methodology and Main Results of the Analytical Work

During the project di erent methodologies were used to collect, complement, check and analyze data as well model di erent solutions. They are described below.

Contact Rate by Health Provider The contact rates for public providers are available at the CPS. To calculate those data for the private sector, the method selected consisted of evaluating the number of patient- visits to a practice or a private hospital every day and multiplying that number by the estimated number of private practices/hospitals (table A.1). 72 World Bank Working Paper

Table A.1 Contact Rate per Health Care Provider

Health structure Contact rate Number of contacts (M)

CSCOM contact ratea 0.23 3.0 Public structures contact rate 0.08 1.1 CSREF contact rateb 0.03 0.4 EPH contact ratec 0.05 0.7 Private commercial structure contact rate 0.10 1.4 Practice contact rate d 0.07 0.9 Private hospital contact rate d 0.04 0.5

Sources: a. Bilan C database. b. SLIS. c. Hospital statistical directory. d. Hypothesis of average visits in practices (10 patients/day) and private hospitals (20 patients/day) and hypotheses on the number of practices (250) and private hospitals (70).

Estimation of the Distribution of Physicians and Private Providers by Region In the absence of data, the estimated distribution of private physicians (table A.2) is based on the hypothesis (validated by the various stakeholders) that 70 percent of all private physicians practice in Bamako, and that the others are distributed in the same pa ern as public sector physicians.

Table A.2 Estimated Distribution of Private Providers, by Region

Indicative number Indicative number Region of private % of split of practices hospitals

Kayes 10 2 13.74%a Koulikoro 9 2 13.31%a Sikasso 16 4 21.95%a Segou 15 4 21.10%a Mopti 11 3 15.30%a Timbuktu 4 1 5.38%a Gao 5 1 7.08%a Kidal 1 0 2.12%a Bamako District 175 49 70.0%b Total except Bamako 75 21 30.0%b Total Mali 250 70 Source: BCG analysis. Note: Hypotheses: Seventy percent of private structures (250 practices and 70 private hospitals) in Ba- mako - The split in the hinterland, except Bamako, is realized applying the same split key than for public physicians (and private, by extension) from data from HR service in the Ministry of Health - a. Percentage of structures outside Bamako b. Percentage of structures in the whole Mali. Private Health Sector Assessment in Mali 73

Average Expenditures at Private Practices and Hospitals The calculation of patients’ average expenditures at private practices/hospitals is based on the calculation of an average expenditure per urban inhabitant (and thus on the hypothesis that only urban dwellers go to those institutions). It assumes the total annual turnover of private practices and hospitals (number of patients per year multiplied by their average expenditure multiplied by the number of providers). This average expenditure per urban inhabitant is then weighted by a coe cient determined by the poverty level in the region (table A.3).

Table A.3. Average Expenditures in Private Practices and Hospitals

Average expenditures in Average expenditure in Region private practices private hospitals (CFA F per urban inhab.) (CFA F per urban inhab.)

Kayes 1,590 1,818 Koulikoro 994 1,136 Sikasso 994 1,136 Segou 994 1,136 Mopti 994 1,136 Timbuktu 1,590 1,818 Gao 1,590 1,818 Kidal 1,590 1,818 Bamako District 2,584 2,954 Total except Bamako 1,292 1,477 Total Mali 1,988 2,272 Source: BCG analysis. Note: Hypotheses: Determination of a national average expenditure per urban inhabitant (supposing only urban people go to private providers) from the “Total turnover of practices-private hospitals/urban population” ratio. A coe cient is then applied to this average expenditure of an urban person according to the poverty area (0.6 in area 1, 0.8 in area 2, 1.3 in area 3)

Estimated Breakevens for Private Practices and Hospitals To calculate market absorption capacity at a constant rate of expenditure, rst, the number of private providers capable of reaching breakeven has to be calculated (i.e., the number reaching an activity level that allows them to cover their costs). In the selected hypotheses, the breakeven of private practices and hospitals is higher in Bamako than in the regions. The number of urban dwellers multiplied by their average expenditure determines the potential turnover of private practices and hospitals. This allows calculation of the number of providers the market can bear at constant expenditure and the number of additional providers that can reach breakeven (table A.4). 74 World Bank Working Paper

Table A.4. Estimated Number of Additional Private Practices and Hospitals that Can Reach Breakeven

Max. Current Potential Potential Private Private Max. Current number number number number of practice hospital number number Region of of of additional additional breakeven breakeven of of private private private private private (M) (M) practices practices hospitals hospitals practices hospitals

Kayes 12 60 45 10 10 2 35 8 Koulikoro 12 60 28 6 9 2 19 4 Sikasso 12 60 43 10 16 4 27 6 Segou 12 60 33 7 15 4 18 3 Mopti 12 60 22 5 11 3 11 2 Timbuktu 12 60 17 4 4 1 13 3 Gao 12 60 24 5 5 1 19 4 Kidal 12 60 2 1 1 0 1 1 Bamako District 18 80 194 50 175 49 19 1 Total except Bamako 12 60 212 49 75 21 137 28 Total Mali 16.2 74 407 98 250 70 157 28 Source: BCG analysis. Note: Breakeven for private practices of CFA F 12M in the regions and 18M in Bamako; breakeven for private hospitals of CFA F 60M in the regions and 80M in Bamako District.

Projected Growth in the Number of Private and Public Physicians Demographic projections were based on the number of medical school graduates, adjusted by assumptions about mortality and rates of departure and return from abroad. Public/private distribution estimates in table A.5 were based on estimated public sector recruitments.

Table A.5. Projected Growth in the Number of Private and Public Physicians

Flow of Stock of Stock of private private public % of private % of public Year physicians physicians physicians physicians physicians

2008 307 1,150 1,233 48.3% 51.7% 2009 285 1,395 1,276 52.2% 47.8% 2010 182 1,533 1,314 53.9% 46.1% 2011 129 1,623 1,349 54.6% 45.4% 2012 103 1,690 1,381 55.0% 45.0% 2013 100 1,749 1,411 55.4% 44.6% 2014 105 1,811 1,440 55.7% 44.3% 2015 109 1,897 1,480 56.2% 43.8% 2016 114 1,964 1,509 56.5% 43.5% 2017 119 2,045 1,543 57.0% 43.0% 2018 124 2,131 1,578 57.5% 42.5% 2019 129 2,209 1,608 57.9% 42.1% 2020 134 2,277 1,634 58.2% 41.8% Source: BCG analysis Note: Hypotheses: Projections of the total number of graduates up to 2014 from the number of students in the rst year and from the numerus clausus in 2008, then beyond 2014 by increasing the education ow by 3 percent each year. Calculation of the ow of physicians joining the private sectors starting from the hypothesis of 50 recruits per year in the public sector. Stock of active physicians calculated from education ows with the hypothesis of a 30-year activity period and an annual mortality rate of 1 percent— hypotheses of 5 percent of foreign graduated physicians, of which 75 percent leave Mali. Private Health Sector Assessment in Mali 75

Estimated Number of New Private Practices and Hospitals Enabled by Settlement of Young Physicians The projected number of private practices andhospitals that will open in the coming years (table A.5) can be calculated from estimated education ows and assumptions about the public/private, hospital/practice distribution of those future young graduates. It is also assumed that the hospital/practice distribution will continue to follow known pa erns (usually two physicians per practice and ve per hospital). Table A.6 shows the funding needs of these new medical establishments.

Table A.6. Estimated Number of New Private Practices and Hospitals Enabled by Settlement of Young Physicians

Flow of physicians Number of private opening their own Number of practices that hospitals that can be Year practice can be opened opened 2008 246 92 31 2009 228 86 29 2010 146 55 18 2011 103 39 13 2012 82 31 10 2013 80 30 10 2014 84 31 10 2015 87 33 11 2016 91 34 11 2017 95 36 12 2018 99 37 12 2019 103 39 13 2020 108 40 13 Source: BCG analysis. Note: Hypotheses: Flow of physicians opening their own practice = 80 percent of the total ow of physicians joining the private sector. Number of practices that can be opened = 75 percent of the ows of physicians opening their own practice and two physicians per practice. Number of private hospitals that can be opened = 25 percent of the ows of physicians opening their own practice and ve physicians per private hospital

Funding Needs of New Private Practices and Hospitals Enabled by Settlement of Young Physicians Table A.7. Funding Needs of New Private Practices/Hospitals Enabled by Settlement of Young Physicians

Practice funding PrivatePrivate hospitalhospital Total funding Year needs (M) fundingfunding needs needs (M) (M) needsneeds (M)(M)

2008 737 614 1,351 2009 684 570 1,254 2010 437 364 801 2011 310 258 568 2012 247 206 453 2013 240 200 440 2014 251 209 460 2015 262 218 480 2016 273 228 501 2017 285 238 523 2018 297 248 545 2019 310 258 568 2020 323 269 592 Source: BCG analysis. Note: Hypothesis: Funding need for se lement of CFA F 8M per practice and CFA F 20M per private hospital. 76 World Bank Working Paper

Funding Rural Physicians Table A.8. Funding Needs Associated with Support of Rural Physicians Flow of physicians Rural physicians Year becoming rural physicians education need (M) 2008 46 334 2009 43 310 2010 27 198 2011 19 140 2012 15 112 2013 15 109 2014 16 114 2015 16 119 2016 17 124 2017 18 129 2018 19 135 2019 19 141 2020 20 146 Source: Santé Sud. Note: Hypotheses: Fifteen percent of physicians join the private sector and becoming rural physicians, average amount of the se lement of a rural physician CFA F 7 260 000. Private Health Sector Assessment in Mali 77

Mutual Insurance Deployment in the Compulsory Subscription Model The hypotheses summarized in table A.9 were constructed starting from the voluntary health insurance managed by the UTM and its members. Comments 35% thein voluntary model voluntarymodel) the in (80% Maximum 90% of rate Amount hospitalization outside only hospital a in hospitalization of Reimbursement Role of simple advocate/representative without centralizationmanagement function of 3 1% 5% 5% 0% 2% 7% 2% 2% 3% 5% 3% 100 75% 75% 10% 75% 50% 15% 99% 50% 20% 2.0% 3,300 2,049 2,250 300 F 23.0% 29,383 10,250 14,000 Hypotheses Value BCG analysis. year penetrationyear rate st Annual growth of penetration rate penetration Annual of growth Number beneficiaries of per subscriber beneficiary per subscription monthly of Price Rate of CSCOM contact perpopulation non-beneficiary non-beneficiary per rate population contact CSCOM of Growth beneficiaries among rate consultation CSCOM beneficiaries among rate consultation CSCOM of Growth consultation CSCOM of cost Actual CSCOM reimbursement rate beneficiaries among rate consultation CSREF beneficiaries among rate consultation CSREF of Growth consultationActual CSREFcost of CSREF reimbursement rate visitsRate pharmacyamong beneficiaries of beneficiariesGrowth pharmacy among rate consultation of visitsActual pharmacycost of Pharmacy reimbursement rate beneficiariesRate among consultation hospital of beneficiaries among Growth consultation hospital of rate Actual consultation hospital cost of Hospital reimbursement rate beneficiaries among consultation hospital practice/priv. private of Rate rate consultation hospital practice/private private of Growth consultation hospital practice/private private of cost Actual rate reimbursement hospital practice/private Private Federative membership rate Provisions reinsurance rates and Number of mutual createdNumber year insurances of per mobilization pool (socialPotential population scale) the pool Potential of rate growth 1 Table A.9. Hypotheses for Modeling Mutual Insurance Deployment under Compulsory Subscription Table Source: 78 World Bank Working Paper

Results of the Mutual Insurance Extension Model (Compulsory Subscription) pop.) in pop.) in 26.58% 27.36% 28.25% 29.29% 30.51% 31.97% 33.77% 36.00% 38.80% 42.36% 46.74% 49.59% 52.78% 56.36% 60.38% 64.91% scenario constant constant Contact rate Contact of CSCOM & & CSCOM of CSREF (total 26.58% 28.97% 32.58% 37.96% 45.86% 57.04% 71.27% 89.14% 106.14% 125.39% 145.12% 147.48% 147.86% 148.26% 148.68% 149.10% Contact rate rate Contact of CSCOM & & of CSCOM CSREF (total of mutual of mutual ins. pop.) with dev. dev. pop.) with 0.0 (M) 711.3 189.0 422.6 1,068.2 1,493.7 1,931.8 2,383.2 2,659.1 2,904.3 3,108.8 3,259.9 3,357.7 3,458.5 3,562.2 3,669.1 provisions provisions Total cost of of Total cost 0.0 50.4 (M) 112.7 189.7 284.9 398.3 515.2 635.5 709.1 774.5 829.0 869.3 895.4 922.3 949.9 978.4 federative federative Total cost of of Total cost subscription subscription (M) Total 1,437.0 2,442.7 3,234.9 4,217.7 5,255.0 6,472.8 7,606.0 7,309.3 7,451.0 7,813.8 7,993.7 8,127.1 8,088.0 8,142.0 8,344.0 8,547.8 management- creation costs costs creation 0.0 228.3 1,392.2 2,933.8 4,586.2 6,270.8 7,791.5 8,783.2 9,126.8 7,289.2 4,345.5 - 4,038.4 - 8,265.1 Technical Technical - 12,094.1 - 15,414.6 - 18,094.0 balance (M) balance - - - - ciaries. 836.4 532.6 337.2 573.3 - 1,269.9 - 1,201.2 - 3,530.1 - 7,147.2 - 1,437.0 - 1,289.9 result (M) - 11,703.3 - 16,294.7 - 20,606.2 - 24,616.8 - 28,270.9 - 31,289.3 Total financial Total financial % of 2.15% 7.17% 13.06% 19.97% 28.14% 37.43% 46.45% 55.21% 59.63% 63.10% 65.49% 66.64% 66.64% 66.64% 66.64% 66.64% coverage 0.3 1.0 1.9 3.0 4.3 5.9 7.5 9.2 (M) 11.1 11.9 Total 10.2 12.5 12.9 13.2 13.6 14.0 persons persons covered number of of number 0.0 0.7 1.6 2.6 4.0 5.5 7.2 8.8 9.8 (M) 11.5 10.8 12.1 12.4 12.8 13.2 13.6 covered covered persons persons Additional of number 0 100 200 300 400 500 600 700 700 700 700 700 700 700 700 700 mutual effective effective number of of number Cumulated insurances BCG analysis. Total number of persons covered: existing base + new bene Total number of persons covered: Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Table A.10. Results of Compulsory Subscription Model Table Source: Note: Private Health Sector Assessment in Mali 79

Hypotheses for Modeling a Typical CSCOM Table A.11. Hypotheses for Modeling a Typical CSCOM

Hypotheses

Population base 13,000 Curative consultation rate 23% Annual growth rate of curative consultation rate 3%

Personnel productivity 500 consult./year Number of personnel subsidized 2

Average consultation price 1,000 CFA F Drug margin 15% Prescription average price 1,200 CFA F Subsidy revenues 0 CFA F

Labor cost per personnel 800,000 CFA F/yr Cost of consumables per consultation 150 CFA F Fixed costs 1,400,000 CFA F

Source: BCG analysis. Note: Established from the database gathering information contained in Bilan C les.

Results of the Modeling of a Typical CSCOM Table A.12. Results of Typical CSCOM Model

SynthesisSynthesis 2009 2010 2011 2012 2013 2014 2015

Consultation revenues (M) 3.0 3.2 3.4 3.6 3.9 4.1 4.3 Drug revenues (M) 3.2 3.4 3.6 3.9 4.1 4.3 4.6 Subsidy revenues (M) 0.0 0.0 0.0 00 0.0 0.0 00 Total revenues (M) 6.3 6.7 7.0 7.4 8.0 8.4 9.0

Number of personnel 6.0 6.0 7.0 7.0 8.0 8.0 9.0 Labor costs (M) 3.2 3.2 4.0 4.0 4.8 4.8 5.6 Fixed costs (M) 1.4 1.4 1.4 1.4 1.4 1.4 1.4 Variable costs (M) 0.6 0.7 0.7 0.7 0.8 0.8 0.9 Drug costs (M) 2.8 2.9 3.1 3.3 3.5 3.7 3.9 Total costs (M) 8.0 8.1 9.2 9.4 10.5 10.7 11.8

Functioning total (M) -2.2 -2.0 -2.7 -2.5 -3.1 -2.9 -3.6 Drug total (M) 0.5 0.5 0.5 0.6 0.6 0.7 0.7 Total (M) -1.7 -1.5 -2.1 -1.9 -2.6 -2.3 -2.9 Source: BCG analysis. 80 World Bank Working Paper

Turnover of the Pharmacy Channel Table A.13. Breakdown of Pharmacy Turnover, 2008 Africalab Turnover Laborex Copharma Asians PPM and Camed % Generics 5% 5% 90% 100% 100% % Specialties 95% 95% 10% 0% 0% Generic costs (M) 0.90 0.40 0.75 3.33 7.50 Specialty costs (M) 17.02 7.52 0.08 Total costs (M) 17.92 7.92 0.83 3.33 7.50 Generic wholesaler margin 20% 20% 20% 20% 20% Specialty wholesaler margin 20% 20% 20% Generic selling price turnover (M) 1.08 0.48 0.90 4.00 9.00 Specialty selling price turnover (M) 20.43 9.03 0.10 0.00 0.00 Total selling price turnover (M) 21.50 9.50 1.00 4.00 9.00 Generic retailer margin 45% 45% 45% 25% 15% Specialty retailer margin 33% 33% 33% Generic selling price T/O (M) 1.56 0.69 1.31 5.00 10.35 Specialty selling price T/O (M) 27.17 12.00 0.13 Total selling price turnover (M) 28.72 12.69 1.44 5.00 10.35 Sources: WHO 2004; BCG interviews, analysis, and modeling. Note: Hypotheses—multiplicative coe cient of 1.20 applied for all wholesalers from the cost price turnover (spec. and generics)

Distribution of Pharmacies and Waiting Lists, by Region Table A.14. Distribution of Pharmacies and Waiting Lists, by Region Number ofof applicants applicants Region Number ofof pharmacies pharmacies in thethe waitingwaiting list list Bamako 190 220 Gao and Kidal 7 3 Kayes 26 23 Koulikouro 57 90 Mopti 14 10 Segou 28 15 Sikasso 37 25 Timbuktu 4 1 TOTAL 363 387 Source: CNOP. Private Health Sector Assessment in Mali 81

Appendix B. Project Approach

Work Stream Complementarity: Analytic and Stakeholder Engagement

In keeping with the project objectives, the report process was structured around two complementary work streams ( gure B.1). The rst work stream was analytic in order to assess through a fact-based approach the role of the private sector in the health system. This allows for analysis of the main components of each health channel (health care delivery, education, pharmaceuticals, insurance) and the potential impact of various evolutions. The second work stream concerns stakeholder engagement in an e ort to enrich the observations, enhance discussions about improvement axes, and sketch out the operational modalities.

Figure B.1. The Project Approach

1st seminar 2nd seminar Finalization

13-14 August 09 26-28 October 09 15 March 2010

Analytical Opportunities Initialization Detailed analysis Detailed plans work stream and levers

Stakeholders implication Preparation Management of dialogue with the various stakeholders work stream

Source: BCG.

All analyses and recommendations in the present report were shared with the main players during the seminars or ad hoc working sessions.

Analytic Work Streams

The analytic work streams allowed estimation of both the size of the private sector in 2009 and its contribution to the whole health sector. The complementary analysis axes as well as the key areas for improvement were also identi ed and shared with all the parties involved in the project. The key analyses were the following: Listing of volume, sector by sector (in particular the distribution in the territory, pu ing perspective on the numbers depending on the population served) Identifying the clinical pathway of the populations Pu ing into perspective the populations’ needs and the health care delivery capacity Modeling the players’ economic equations (CSCOMs, practices/private hospitals, pharmacies, private mutual insurance)—integrating their projected evolution path Identifying the regulatory framework and the factors a ecting the ease of con- ducting business in the health sector. 82 World Bank Working Paper

This work drew on existing studies, databases provided by the administration and the di erent councils, interviews with health professionals, as well as complementary analyses of the clinical pathway of populations through an opinion survey of 1,050 households. The systemic dimension of the whole sector was been identi ed, and the approach was been structured to take into account the reciprocal impact of each component. (For example, the impact of health insurance on the utilization rate and the viability of primary health care providers were considered).

Stakeholder Engagement Work Stream

The stakeholder engagement phase started at the beginning of the project, in order to identify all players working within or for the health sector. This work included three seminars. Seminar 1, August 13–14, 2009. Objectives were to • reinforce understanding among the players (stakes/resources/constraint sessions) • share early ndings and rst leads • ensure the participation of all in the project Seminar 2, October 26–28, 2009. Objectives were to • share and re ne the diagnosis • elaborate, together with the stakeholders, on the improvement axes and pri- oritize them • agree on the rst implementation modalities Seminar 3, March 15, 2010. Objectives were to nalize and validate the action plans. In addition, almost 100 stakeholders were interviewed in Bamako and the regions, in order to go in-depth in the analyses with the players, sketch out leads for improvements, and con rm the potential impact. Appendix F lists the main institutions and personalities involved in the interviews, working groups, and seminars led by BCG. Private Health Sector Assessment in Mali 83

Appendix C. Terms of Reference of the Steering Committee Ministry of Health Republic of Mali General Secretariat Planning and Statistics Unit TERMS OF REFERENCE OF THE STEERING COMMITTEE Study on the Private Health Sector in Mali

Context

In the framework of the Health Initiative in Africa, the Department of the conditions favorable to the investment of the World Bank (CIC), in close cooperation with the Health and Education Department of the International Finance Corporation (IFC) and the Ma- lian government (the Ministry of Health) hired international consulting rm The Boston Consulting Group (BCG) to conduct an assessment of the private health sector in Mali. The main objective of BCG’s mission has been to work in close collaboration with the Malian government in order to formulate recommendations about a program of reforms, to reinforce the general political framework that de nes the interface between the public and private health sectors, and to improve the organization of health-related goods and services for the whole population. The objectives of the study consist of: Determining very precisely the role that the private sector currently plays in achieving health results in the country; Diagnosing the nature and e cacy of the interface between the public and private sectors in Mali, as well as the general framework of the economic activity and the investment, and the adaptation possibly required to promote the private health sector in order to reach health objectives; Helping the government and the political managers concerned to initiate a dialogue with health system stakeholders—in particular with private sector stakeholders—in order to mobilize additional resources for health care and improve access and coverage; and Facilitating, in partnership with the Ministry of Health, the formulation of the detailed recommendations to provide an environment favorable to the development of the private sector and of the public-private partnership in order to reach together the public health objectives. In this framework, BCG will speci cally have to: 1. Design the analytical framework of the study 2. Collect and analyze data 3. Involve the stakeholders 4. Lead at least three workshops for the stakeholders 5. Facilitate the formulation of the recommendations for a reform program To help the concrete realization of this work, the Malian Government established a Steering Commi ee that would support, direct, and supervise the course of the work on the eld. The present terms of reference detail the objectives, the mandate, the composition, and the operating mode of the Commi ee. 84 World Bank Working Paper

Objective

The objective of the Steering Commi ee is (i) to make the work of diagnosis progress by ensuring/facilitating a strategic leadership and an orientation of the assessment work in Mali; (ii) to serve as an adviser, to ratify strategic decisions, and to facilitate the process underway. As such, the Steering Commi ee will supervise and monitor the implementation of all the components of the study, in particular the “analytical section,” the “mobilization/involvement section,” and the “recommendation section.”

Mandate

The Steering Commi ee has the roles/missions of: 1. Ensuring the follow-up of the work according to the planning, which will be de ned, and the success indicators contained in the TDRs of the study; 2. Facilitating as much as possible the realization of the consultant’s work; 3. Facilitating the common understanding of the assessment work and monitoring the working program for its implementation; 4. Examining and validating the reports produced by the consultant (BCG) at each step, and ensuring the internal review process of these reports; 5. Discussing the operational conclusions likely to be drawn from the studies and the assessment achieved, and ensuring the national public-private partnership strategy is updated; 6. Ensuring the circulation of information about this study and its potential consequences inside and outside the Ministry of Health.

Composition and Functioning

The chair of the Steering Commi ee is the Director of the CPS (Planning and Statistics Unit of the Ministry of Health). The commi ee will be limited to a maximum of 11 members, two representatives from the Ministry of Health (including one member of the PRODESS steering commi ee—representative from the CPS—and the second member representing the DNS), two representatives from the World Bank Group (WB/IFC), two representatives from the consulting rm (BCG), one representative from the other Tech- nical and Financial Partners (PTF) providing their support to the health sector in Mali, one representative from constituted medical entities (council of pharmacists and/or council of physicians), one representative from the Ministry of Finance, and one representative from the Institute of Statistics (ex. DNSI). It is imperative that the members of the Steering Commi ee are able to represent their institutions at a senior level, due to the importance and the sensitivity of the issues addressed and in order to perform advising and orientation tasks and to ensure quick and e cient decision making. The Steering Commi ee meets once every 15 days, and as needed, upon request from its President. The Steering Commi ee will meet, in person or through means of audio (conference call) or video (videoconference). The CPS will ensure the secretariat of the Steering Commi ee meetings. The summary of each meeting will be established and shared with all the partners involved. Private Health Sector Assessment in Mali 85

Appendix D. Malian Household Survey Questionnaire on Health Behavior

A. Identi cation

A.1. Nr. of questionnaire A.6. Region A.10. Person surveyed Man Woman

A.2. Surveyor A.7. Circle/Town A.11. Size of the household Children Children Less than 1-5 years 5-18 years 1 year old old Adult Total A.3. Checkers A.8. Village

A.12. Scale of household revenues A.4. Nr. Computing agent A.9. Nr. households in the group 1. Less than 500,000 per year 2. Less than 1 million per year 3. Between 1 and 2 million per year 4. Between 2 and 3 million per year A.5. Date 5. Between 3 and 4 million per year Day/month/2009 6. More than 5 million per year 98. Don’t know A.13. Implantation area 1. Urban 2. Rural

B. Clinical pathway B.1. Within the last twelve months, have you or a member of your family been sick?

1. Yes 2 No (End of the interview)

B.1.1. IF YES, WHICH AMONG THE FOLLOWING SICKNESSES HAPPENED TO YOU AND THE MEMBERS OF YOUR HOUSEHOLD? (PUT THE NUMBER OF OCCURRENCES PER AGE BRACKET) Children Children Children Adults 0-1 yr (A) 1-5 yr (B) 5-18 yr (C) (D) 1. Pathologies / event 1.1 Fever / malaria 1.2 Diarrhea 1.3 Back / limb / articulation pain 1.4 Cough 1.5 Skin problem 1.6 Eye problem 1.7 Tooth problem 1.8 Injury / fracture / sprain 1.9 Blood pressure / diabetes 97 Other (to be speci ed) 2. Mother care 2.1 Pre-birth consultation 2.2 Deliveries 2.3 Post-birth consultation 86 World Bank Working Paper

B.1.2. DO YOU HAVE AN IDEA OF HOW MUCH YOU HAVE SPENT IN TOTAL FOR HEALTH IN YOUR HOUSEHOLD DURING THE LAST 12 MONTHS?

1. Yes (Go to question B.1.3. 2. No (Go to question B.1.4)

B.1.3. IF YES, IN WHICH COST AREA WOULD YOU PLACE YOUR HOUSEHOLD? (CIRCLE A CODE) 1. Less than 5,000 CFA F 2. 5,000 and 10,000 CFA F 3. 10,000 and 20,000 CFA F 4. 20,000 and 30,000 CFA F 5. 30,000 and 40,000 CFA F 6. 50,000 and 100,000 CFA F 7. 100,000 and 200,000 CFA F 8. More than 500,000 CFA F

We will choose three diseases among the ones you have listed about which we will ask the following questions

List of selected diseases Pathologies/event 123456789 ABCDABCDABCDABCDABCDABCDABCDABCDABCD

Mother care 10 11 12 CDCDCD

B.1.4. FIRST DISEASE SELECTED (PUT THE CODE: ) Information is collected about the last episode in case there have been several episodes of the same disease.

B.1.4.1. When you or a member of your household was a ected by the disease, what did you do?

1. You did nothing (if yes, go to the 2nd disease) 2 You treated yourself alone (if yes, answer question B.1.4.2) 3 You consulted someone / took advice (if yes, answer question B.1.4.3) (Answers 2 and 3 are not exclusive; if you circle both, you must answer both questions and the rest of the questions about the rst disease. If you only circled answer 2, you answer only question B.1.4.2) Private Health Sector Assessment in Mali 87

B.1.4.2. When you treated yourself alone for the last time: a) What did you do? 1 Bought herbs 2 Looked for herbs 3 Used drugs from the illegal pharmacy market 4 Used drugs from a pharmacy 97 Other (Specify) Answers are not exclusive. b) How many times did you do it? (put the number in the cell below)

c) How much did it cost you on average? (put the amount in the cell below)

B.1.4.3. Last time you or a member of your family went to consult someone/looked for advice, where did you go?

Code Entity consulted 1 A member of your family 2 A traditional practitioner 3 A traveling healer 4 A medical practice 5 A CSCOM 6 A CSREF 7 A private hospital 8 A hospital 97 Other (Specify) (Circle the appropriate codes)

B.1.4.4. Classify the consultations according to their order of occurrence

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

B.1.4.5. How much time elapsed between consultations?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

For the 1st consultation = duration between the appearance of the disease / accident and the 1st time episode of seeking care for it. 88 World Bank Working Paper

B.1.4.6. Who made the decision to consult someone outside the household?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Yourself 2 The head of the family 3 A relative 4 A neighbor 97 Other (Specify)

B.1.4.7. Who took charge of the expenses related to the care provided by the di erent consultations?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Yourself 2 Family 3 Village 4 Mutual insurance 5 NGO / association 6 Friends 7 Visitors 97 Other (Specify)

B.1.4.8. How much did the consultation, the drugs prescribed, and transportation to care cost?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Consultation 2 Drugs 3 Transport 4 Total amount 98 Don’t know

B.1.4.9. How long did you wait to get the treatment?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Less than one hour 2 2 hours 3 More than 2 hours 4 The whole morning 5 The whole day 97 Other (Specify) 98 Don’t know Private Health Sector Assessment in Mali 89

B.1.4.10. How did you choose that provider?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Trust 2 Proximity 3 Affordable cost 4 Medical expertise 97 Other (Specify)

B.1.5. FIRST DISEASE SELECTED (INSERT THE CODE: EXAMPLE 2D) Information is collected about the last episode in case there have been several episodes of the same disease.

B.1.5.1. When you or a member of your household were a ected by disease 2D, what did you do?

1 You did nothing (if yes, go to the 2nd disease) 2 You treated yourself alone (if yes, answer question B.1.4.2) 3 You consulted someone / took advice (if yes, answer question B.1.4.3)

(Answers 2 and 3 are not exclusive. If you circle both, you must answer both questions and the rest of the questions about the rst disease. If you only circled answer 2, you answer only question B.1.5.2.

B.1.5.2. When you treated yourself alone the last time: a) What did you do? 1 Bought herbs 2 Looked for herbs 3. Used drugs from the illegal pharmacy market 4 Used drugs from a pharmacy 97 Other (Specify) Answers are not exclusive b) How many times did you do this? (put the number in the cell below)

c) How much did it cost you on average? (put the amount in the cell below) 90 World Bank Working Paper

B.1.5.3. The last time you or a member of your family consulted someone/sought advice, where did you go?

Code Consultation 1 A member of your family 2 A traditional practitioner 3 A traveling healer 4 A medical practice 5 A CSCOM 6 A CSREF 7 A private hospital 8 A hospital 97 Other (Specify) (Circle the consultation codes)

B.1.5.4. Classify the consultation according to order of occurrence

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

B.1.5.5. How much time elapsed between consultations?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

For the 1st consultation = duration between the appearance of the disease / accident and the 1st episode of seeking care

B.1.5.6. Who made the decision to consult someone outside the household?

B.1.5.7. Who took charge of the expenses related to the care provides by the various consultations?

B.1.5.8. How much did the consultation, drugs prescribed, and transportation cost?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Consultation 2 Drugs 3 Transport 4 Total amount 98 Don’t know

B.1.5.9. How long did you wait to get the treatment?

B.1.5.10. How did you choose that provider?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Trust 2 Proximity 3 Affordable cost 4 Medical expertise 97 Other (Specify)

B.1.6. THIRD DISEASE SELECTED (PUT THE CODE: EXAMPLE 10D) Information is collected about the last episode in case there have been several episodes of the same disease.

B.1.6.1. When you or a member of your household were a ected by disease 10D, what did you do?

1 You did nothing (if yes, go to the 2nd disease) 2 You treated yourself alone (if yes, answer to question B.1.4.2) 3 You consulted someone / took advice (if yes, answer question B.1.4.3) (Answers 2 and 3 are not exclusive. If you circle both, you must answer both questions and the rest of the questions about the rst disease. If you only circled answer 2, you answer only question B.1.6.2) B.1.6.2. When you treated yourself alone for the last time: a) What did you do? 1 Bought herbs 2 Looked for herbs 3 Used drugs from the illegal pharmacy market 4 Used drugs from a pharmacy 97 Other (Specify) Answers are not exclusive b) How many times did you do this? (put the number in the cell below)

c) How much did it cost you on average? (put the amount in the cell below)

B.1.6.3. The last time you or a member of your family went to consult someone/sought advice, where did you go?

B.1.6.4. Classify the consultation according to order of occurrence

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

B.1.6.5. How much time elapsed between consultations?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Consult Consult Consult Consult Consult Consult Consult Consult Consult

*For the 1st consultation = duration between the appearance of the disease / accident and the 1st episode of seeking care Private Health Sector Assessment in Mali 93

B.1.6.6. Who made the decision to consult someone outside the household?

B.1.6.7. Who took charge of the expenses related to the care provided by the various consultations?

B.1.6.8. How much did the consultation, drugs prescribed, and transportation cost?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Consultation 2 Drugs 3 Transport 4 Total amount 98 Don’t know

B.1.6.9. How long did you wait to get the treatment?

B.1.6.10. How did you choose that provider?

1st 2nd 3rd 4th 5th 6th 7th 8th 9th Code Answers Consult Consult Consult Consult Consult Consult Consult Consult Consult 1 Trust 2 Proximity 3 Affordable cost 4 Medical expertise 97 Other (Specify)

C. Feedback about health care providers C.1. Rank in order of importance the different evaluation criteria of health care providers:

Code Evaluation criterion Order of importance 1 Ef cacy of the cure 2 Adequate distance 3 Adequate consultation price 4 Adequate prescription price 5 Drug availability 6 Competence of the personnel 7 Quality of welcome / listening 8 Cleanliness of premises 9 Quality of the equipment (Two criteria cannot have the same importance)

C.2. Which mark would you give to the health care providers according to the descriptions below? (1: very insu cient; 2: insu cient; 3: average; 4: good; 5: very good; 6: outstanding)

Traditional Traveling Medical Private Criteria practitioner healer practice CSCOM CSREF hospital Hospital Ef cacy of the cure Adequate distance Adequate consultation price Adequate prescription price Drug availability Competence of the personnel Ethics of the personnel Cleanliness of premises Quality of the equipment Put the mark given by the participant for each provider. In case no mark is given, put “Don’t know” or 99

We thank you for your participation. Private Health Sector Assessment in Mali 95

Appendix E. Sampling Method for the Malian Household Survey of Health Behavior

Survey Base

The populations of four Regions were used by statistics services to determine the size of the sample. Thus, the Regions of Kayes, Sikasso, Gao, and the District of Bamako have already been selected according to a reasoned choice. According to such a choice, the areas with urban towns have been selected in each of the four Regions. These areas are Kayes and Kita in the Region of Kayes, Bougouni and Sikasso in the Region of Sikasso, Gao and Ansogo in the Region of Gao, and the towns of the District of Bamako. The de nitive list of the towns surveyed is in the table below.

Regions Areas Urban towns Rural towns Kayes Kayes Kayes Sadiola 13 towns Diamou Ségala Kouniakari Bangassi Kita Kita Sébékoro Séfeto Kassaro Boudoufo Kita rural Djidian D. Bamako Towns Towns I, II, III, IV, V, et VI 6 towns Sikasso Sikasso Sikasso Niéna 13 towns Bliendio Farakala Kléla N’Kourala Bougouni Bougouni Kéléya Sido Zantiébougou Koumantou Faragaran Dogo Gao Gao Gao Gabero 8 Towns Soni Ali Ber Gounzoureye Ansongo Ansongo Bara Boura Ouattagouna Total 6 areas + the District of BKO 13 27 40 towns 96 World Bank Working Paper

Characteristics of the Sample Sample Size The survey used a sample composed of three regional capitals and the District of Ba- mako, eight areas, 40 towns. The sample included 1,050 households. The towns were structured in two layers—rural and urban. The sorting of the towns was made at random within the two layers. Thus, 13 towns were selected in the Region of Kayes, 13 in the Region of Sikasso, six in the District of Bamako, and eight in the region of Gao.

Process for Random Selection of Households At the level of the main towns, a sample of 25 households was chosen at random from a list of total households, in compliance with the protocol below: The households were selected at random by systematic drawing done independent- ly in each town. The heads of households were interviewed. To manage the questionnaire, the con- cession was located and then the selected household was identi ed. Taking into account the con guration of the households, and to respect habits and customs, the team of surveyors and the supervisor visited the village head in order to: Inform the village head and his advisers about the objective of the survey Draw up a list of all households in the village (if the list was not available). With the help of the village head, the selected households were easily identi ed. Twenty- ve households were selected in each town.

Steps in Selection Procedure The households in each town were selected in the following steps: Step 1: Assign a number to each household in the list Step 2: Determine the reason “R” (i.e., the selection pace) as follows: R = total number of households in the town 25

Step 3: Select a random number (). For this, read at random in the table numbers with n gures (n being the number of gures in the whole part of R), a number between 1 and whole R. The random number () selected in order, in the survey basis of the rst household. Step 4: Selection of the other households: Create an arithmetic progression of 25 numbers with as base and for reason R (the selection pace), in the following way: corresponds to the rst household selected + R corresponds to the second household selected + 2R corresponds to the third household selected + 3R corresponds to the fourth household selected + (n1)R corresponds to the thirtieth household selected Step 5: Survey number: Allocate a sequential number from 1 to 25 for all the households selected in the town. Private Health Sector Assessment in Mali 97

Appendix F. Institutions and Individuals Associated with the Work on Stakeholder Engagement The observations summarized in this report were shared with the 60 and more share- holders during the seminars held on August 13–14, 2009; October 26–28, 2009; and March 15, 2010; during the meetings of the project monitoring commi ee; and lastly during the meeting of the extended cabinet of November 16, 2009. To those o cial meetings, we should add the numerous informal interactions that the BCG team had with the players in the Malian health care system during the project (more than 100 interviews).

Representatives from the Administration and Semi-public Organizations GS—technical advisers to the minister (M. Bouaré)—IS—CPS—DNS—DPM—DAF— DRH—PPM—FMPOS—INFSS—INSTAT—INRSP—CNIECS—API

Ministry in charge of the promotion of women—Ministry in charge of higher education— Ministry in charge of employment and professional training—Ministry in charge of social development (DNPSS)—Ministry of the administration and territorial communities

Representatives from the Civil Community and the Private Sector CNOM—CNOP—CNOSF—AMLM—GPSP—Association of private schools—Associa- tion of the midwives—Association of the young pharmacists—SYNAPO—Association of nurses—Laborex—Africalab—AMC—Santé Sud—UTM—FENASCOM—FEMATH— Aga Khan Foundation—CCIM—Kafo Jiginew—APBEF—Clinique Pasteur—Hôpital Luxembourg Mère enfant—Centre Mérieux

Representatives from Technical and Financial Partners WHO—FNUAP—UNICEF—Netherlands—France (SCAC and AFD)—USAID—Canada

————— Note: In the course of the project, the Boston Consulting Group made trips to Ségou and its surroundings, in the Kayes, Mopti, and Gao regions.

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